Older people falling out of bed: restraint, risk and safety.
Article Type: Report
Subject: Aged patients (Accidents)
Aged patients (Safety and security measures)
Falls (Accidents) (Prevention)
Hospital beds (Design and construction)
Occupational therapists (Practice)
Author: Hughes, Rhidian
Pub Date: 09/01/2008
Publication: Name: British Journal of Occupational Therapy Publisher: College of Occupational Therapists Ltd. Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2008 College of Occupational Therapists Ltd. ISSN: 0308-0226
Issue: Date: Sept, 2008 Source Volume: 71 Source Issue: 9
Topic: Event Code: 260 General services; 200 Management dynamics
Product: Product Code: 2599020 Hospital Beds NAICS Code: 339113 Surgical Appliance and Supplies Manufacturing SIC Code: 2599 Furniture and fixtures, not elsewhere classified
Geographic: Geographic Scope: United Kingdom Geographic Code: 4EUUK United Kingdom
Accession Number: 185654392
Full Text: Opinion

Bedside rails are used for older people's safety in order to prevent them from falling out of bed and suffering injury. Bed rails can constitute restraint and the principles underpinning mental capacity legislation illustrate good practice when equipment is used in ways that may restrict people's freedom. The use of bed rails illustrates broader tensions in the care of older people: tensions between ensuring the safety of older people and maintaining independence and freedom, including older people taking risks. Person-centred care emphasises that the views of older people, their family carers and the professionals must all be taken into account when assessing older people's care needs and developing risk assessments and care plans. There needs to be further education and debate about positive practice in the use of bed rails because, all too often, the use of these devices is taken for granted. Staff need support to ensure that they put the best interests of older people at the centre of all decisions about their care.

Key words: Older people, bed rails, restraint.

Falls, risk and safety

Older people who fall out of bed risk injury. People may fall accidentally because they slip or slide from the bed when they move to reposition themselves or when they are agitated, anxious or confused. There are a number of techniques that are used as a barrier or an obstacle to prevent people falling out of bed. Bedside rails form a barrier to contain individuals within the bed and are used for the safety of older people. They are used across health and social care settings, including people's own homes, care homes, hospitals and hospices. Bedside rails can help to prevent older people from falling from bed and injuring themselves. However, this equipment may also be used to prevent people from leaving a bed and, in these circumstances, may constitute restraint. Furthermore, bed rails may act as a psychological barrier to discourage people from leaving their bed, especially when they are agitated or confused. Bed rails have even been described as a form of 'imprisonment' (Dimond 2004).

Occupational therapists, both in the United Kingdom (UK) and overseas, have raised concerns about the use of restraints (Carruthers 2001, Dimond 2004, Lavery 2005). A broad definition of restraint emphasises the restriction of someone's freedom. More specifically, it is important to define the ways in which people's freedom can be restricted:

The unnecessary limits to people's independence or choice in decisions about their own health and social care arrangements and lives sit uncomfortably with the principles of person-centred care in occupational therapy. Safe therapeutic environments, characterised by a philosophy of least restraint, and the promotion of independence are hallmarks of good quality practice. Lavery (2005) suggested that risk prevention was overemphasised in discussions about restraints and argued that there should be a sharper focus on people's rights. She noted that families and carers might place undue pressure on professionals to use restraint when the focus must first be on the rights of the older person himself or herself. This may not necessarily mean putting safety first.

Bedside rails tend to be used for safety reasons; however, they have not been found to reduce the incidence of bed-related falls and injury (Capezuti et al 2007). They may even constitute a risk to older people in bed, because people may fall from a greater height as they try to haul themselves over the rails. Rails used on beds that are not designed for the equipment, or rails that do not take into account individuals' size and weight, can cause additional problems (Hignett and Griffiths 2005). People have become entrapped in the bars and, in some extreme cases, this has led to people dying from asphyxiation (Meikle 2001). Other consequences associated with containing people in bed include reductions in their mobility, pressure sores and incontinence (Oliver 2002). More practically, it can also be difficult to interact with people through bed rails (O'Keeffe 2004).

It is important for occupational therapists to be aware of the debates and research evidence on the use of bed rails because they will encounter them in many health and social care services for older people. In some situations (for example, domiciliary care), occupational therapists may need to assess and prescribe bed rails for older people. In these cases, occupational therapists will need to inform the older person and everyone involved in his or her care about how to operate the equipment safely, as well as making people mindful of the risks associated with its use. In any setting where bed rails are being used, occupational therapists should keep a watching brief to ensure that they are being used safely and in ways that do not undermine people's dignity or respect.

The National Patient Safety Agency review

The National Patient Safety Agency (NPSA 2007a) undertook a systematic review on bed rails. The study found the following:

* There were few scientific studies on the use of bed rails and there was a tendency for the existing literature to focus on the use of bed rails causing harm

* Bed rails that stop people who want to get out of bed constitute restraint; however, it is likely to be an ineffective technique because people instinctively attempt to climb over the rails

* Published rates of bed rail use in UK hospitals range from 8% to 35%

* At least 25% of patient falls in hospitals are falls from bed

* The risk of fatal entrapment in bed rails in hospitals was less than one in 10 million admissions, whereas the risk of falls is one in 200 people receiving care in hospital.

The evidence suggests that a careful balance needs to be struck between the risk of people being injured because of bed rails and being unduly restrained because of the risk of falling out of bed. Decision making therefore needs to be based on individual assessments of risks and benefits. The NPSA (2007b) published a number of supporting documents on bed rail safety, including publicity illustrating the critical and often unresolved issues surrounding the use of bed rails, restraint, risk and safety (see, for example, Fig. 1).


Bed rails as restraint?

There is an important debate to be had about the proper use of bed rails. All techniques that attempt to contain people within bed without due reason constitute restraint, but preventing people from falling out of bed to prevent injury is not a form of restraint. However, if used inappropriately, restraining techniques and equipment, such as bed rails, can be illegal. Mental capacity legislation--Adults with Incapacity (Scotland) Act 2000, Mental Capacity Act 2005--makes it clear that restraint can occur whether or not the person involved is resisting actively. Mental capacity principles and procedures tend to apply to people in the advanced stages of dementia, for example. However, these principles and procedures for restraint highlight good practice for all staff in all situations when using care techniques or equipment that may restrict people's freedom (see Table 1).

Any use of physical restraint requires three key principles to be followed. First, with regard to people's behaviour that requires restraint, the underlying causes need to be carefully understood. With regard to the use of bed rails with older people, the Mental Welfare Commission for Scotland (MWCS 2006) pointed to the need for the perspectives of older people and the causes for older people's restlessness, which might contribute to their risk of falling from bed, to be fully understood. Non-restrictive and therapeutic interventions should be employed first. The MWCS (2006) suggested that this might include, for example, putting the mattress on the floor, as long as it was not done in a demeaning way. Bed rails, when seen as a restraint device to restrict people's freedom of movement, should be considered as the last resort for managing people's behaviour.

Second, the best interests of the individual should be put at the centre of any decision to proceed with restraint. A person-centred plan should be drawn up, ideally in consultation with the older person himself or herself, and certainly with family carers and with other professionals, including advocates where necessary. Older people should be able to exercise control and choice about the equipment or techniques that may be used on them, which includes ceasing their use.

The wishes of carers and relatives should also be taken into account. The NPSA (2007a) review found that people receiving care did not object to the use of bed rails, although family carers were aware of their potential harm. When bed rails restrain people, complex issues arise. Family carers consulted in a Commission for Social Care Inspection (CSCI 2007) report into the restraint of older people illustrated the complex issues at work. Bed rails were felt to keep people safe and this feature was important for the carers. However, in some situations (for example, when people were agitated, delirious or 'wandering', as in the case of dementia), older people could try to climb over the rails. In one such situation cited by CSCI (2007), a very frail person with vascular dementia fell over the rails and broke her hip.

Third, restraints should only be used when there is serious risk of harm to the older person. The relative risk of using a restraint, versus not using a restraint, should be subject to a risk assessment. Decisions should be recorded and the least restrictive technique justified. Records on restraint should be subject to regular management review. When people have become entrapped in bed rails, this should be reported locally, including to the National Reporting and Learning System where appropriate. The Health and Safety Executive (2007) described best practice guidelines in relation to risk assessments (see Table 2).

The CSCI (2007) study into the use of restraint identified a number of staff uncertainties. Some staff were found to be confused about what constitutes restraint. The study also found that staff were unsure about how to balance the rights of people with their own care and safety responsibilities. This can mean that staff may restrain the people being cared for without actually knowing it, and without due attention to the least restrictive options available.

Concluding comments

The key message from this opinion piece is that it is important to recognise that interventions that stop older people from falling out of bed may also prevent people from leaving their bed voluntarily. It is important to recognise the perspectives that different people will have about the use of bed rails and other forms of restraint. There can be tensions between the perspectives of older people, family carers and staff (CSCI 2007). For example, older people will value their freedom highly; however, family carers can also be concerned about people's safety. The difficult task of occupational therapists is to balance these sometimes conflicting views and--ultimately--to put the needs and wishes of older people first.

Irving's (2002) analyses of the professional discourses governing the use of restraint added further complexity to the discussion. She noted how staff could feel that safety must be the highest priority for older people to be protected. If this was not to be the case then the opposite view, that people should be free to do exactly what they wanted and to incur the risks that this entailed, therefore prevailed. Irving (2002, p410) noted the inherent dangers in these polarised views, which 'silently packages restraints as humane and caring, despite the obvious contradictions this represents'.

To curtail someone's freedom may be illegal if the correct policies and procedures have not been followed. A careful balance needs to be struck between respecting people's rights and making decisions about care. There are important national and international principles at stake. In the UK, the Human Rights Act 1998 encourages fairness, respect, equality, dignity and autonomy for all. These principles reflect basic needs that enable us all to live full lives with maximum dignity and respect.

Human rights principles are at the heart of high quality occupational therapy theory and practice and these principles dictate that people should be put at the centre of all decisions about their care, in a person-centred way. This approach will help to improve people's experiences of care, the quality of their lives, and their health and wellbeing. All health and social care services need to be attuned to human rights and occupational therapists have an important role in ensuring that human rights principles are meaningfully integrated into the routines of practice. There needs to be further education and debate on the use of bed rails in occupational therapy. Ultimately, all staff involved in the care of older people need support to ensure that they follow best practice when working with older people at risk of falls and injury.

Submitted: 15 March 2008. Accepted: 22 July 2008.


Adults with Incapacity (Scotland) Act (2000) Available at: http://www.opsi.gov.uk/legislation/scotland/acts2000/asp_20000004_en_1 Accessed on 10.09.08.

Capezuti E, Wagner LM, Brush BL, Boltz M, Renz S, Talerico KA (2007) Consequences of an intervention to reduce restrictive side rail use in nursing homes. Journal of the American Geriatrics Society, 55(3), 334-41.

Carruthers W (2001) Restraints: the blur between safety and human rights. Occupational Therapy Now (online version), 3(4). Available at: http://www.caot.ca/otnow/july01-eng/july01.cfm Accessed on 10.07.08.

Commission for Social Care Inspection (2007) Rights, risks and restraints. An exploration into the use of restraint in the care of older people. London: CSCI.

Department for Constitutional Affairs (2007) Mental Capacity Act 2005. Code of practice. London: Stationery Office.

Dimond B (2004) Legal aspects of occupational therapy. 2nd ed. Oxford: Blackwell.

Health and Safety Executive (2007) Bed rail risk management. London: HSE.

Hignett S, Griffiths P (2005) Do split-side rails present an increased risk to patient safety? Quality and Safety in Health Care, 14(2), 113-16.

Human Rights Act (1998) Available at: http://www.opsi.gov.uk/ACTS/acts1998/ukpga_19980042_en_1 Accessed on 10.09.08.

Irving K (2002) Governing the conduct of conduct: are restraints inevitable? Journal of Advanced Nursing, 40(4), 405-12.

Lavery K (2005) Restraint: Whose choice? Whose risk? Whose decision? Journal of Dementia Care, September/October, 12-13.

Meikle J (2001) Faulty bed rails blamed for deaths of 15 patients. Society Guardian, 31 May.

Mental Capacity Act (2005) Available at: http://www.opsi.gov.uk/ACTS/acts2005/ukpga_20050009_en_1 Accessed on 10.09.08.

Mental Welfare Commission for Scotland (2006) Rights, risks and limits to freedom. Principles and good practice guidance for practitioners considering restraint in residential care settings. Edinburgh: MWCS.

National Patient Safety Agency (2007a) Bedrails--reviewing the evidence. A systematic literature review. London: NPSA.

National Patient Safety Agency (2007b) Using bedrails safely and effectively. Available at: http://www.npsa.nhs.uk/patientsafety/alerts-and-directives/notices/bedrails/ Accessed on 10.07.08.

O'Keeffe ST (2004) Down with bedrails? Lancet, 363(9406), 343-44.

Oliver D (2002) Bed falls and bedrails--what should we do? Age and Ageing, 31(5), 415-18.

Retsas AP (1998) Survey findings describing the use of physical restraint in nursing homes. International Journal of Nursing Studies, 35(3), 184-91.

Correspondence to: Dr Rhidian Hughes, Visiting Senior Lecturer, King's College London, Strand, London WC2R 2LS. Email: rhidian.hughes@kcl.ac.uk

Reference: Hughes R (2008) Older people falling out of bed: restraint, risk and safety. British Journal of Occupational Therapy, 71(9), 389-392.
... any device, material or equipment attached to or near
   a person's body and which cannot be controlled or easily
   removed by the person and which deliberately prevents
   or is deliberately intended to prevent a person's free body
   movement to a position of choice and /or a person's normal
   access to their body (Retsas 1998, p186).

Table 1. Restraint and the Mental Capacity Act 2005

Restraint is defined as:

   Use force--or threaten to use force--to make someone do something
   that they are resisting, or restrict a person's freedom of movement,
   whether they are resisting or not.

To restrain someone who lacks capacity lawfully requires the following
two conditions to be met:

   The person taking action must reasonably believe that restraint is
   necessary to prevent harm to the person who lacks capacity, and the
   amount or type of restraint used and the amount of time it lasts
   must be a proportionate response to the likelihood and seriousness
   of harm.

Source: Department for Constitutional Affairs (2007, pp105-106).
(Emphases in original.)

Table 2. Risk assessment best practice guidelines

* Is alternative equipment more appropriate--are bed rails actually
Other methods of bed management may be appropriate for some people
who use care services. It should be remembered that the actual decision
whether or not to use bed rails is a clinical decision and therefore
one in which health and safety inspectors should not become involved.
However if a decision is taken that bed rails are required, and they
are not provided, then there may be a contravention of HSW Act s.3.

* Is the bed rail chosen suitable for use in combination with the bed,
mattress and occupant. For example, is the occupant's head or body
small enough to pass through the bed rail bars? Is there a gap between
the bed rail and the side of the mattress that will allow the occupants
body to pass through or trap their head? Has suitable advice and
instruction been sourced from the bed rail supplier or manufacturer?

* Is the bed rail fitted correctly to the bed and is it secure? Note
that different fittings may be required for different types of beds
such as hospital or divan. Electric profiling beds have integrated bed
rails that may overcome this issue.

* Are there any gaps present when the bed rail is fitted to the bed
that potentially will allow the occupant to become trapped? BS EN
1970:2000 'Adjustable Beds for Disabled Persons' specifies requirements
and dimensions for bed rails intended for use by people over 12 years

* Is there a regular 'in use' check made by a responsible person, to
ensure that the bed rails remain properly adjusted and continue to be
suitable for the patient?

* If either the bed, mattress, occupant or bed rail is changed, the
risk assessment should be carried out again.

Source: Health and Safety Executive (2007, paragraph 13).
Reproduced under the terms of the Click-Use Licence (www.opsi.gov.uk).
(Emphasis in original.)
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