The highly emotive debate on bedrails has obscured the real issue of weighing up the risks and benefits for each individual patient, argues Frances Healey
In 1984 The Lancet published an editorial castigating the use of bedrails, suggesting that their use was as inappropriate and outdated as ‘the use of fetters in schizophrenia’ (anon, 1984).
At that time, I was a newly qualified staff nurse, with memories of my ‘geriatric’ placement in a former workhouse fresh in my mind – a unit with caring nursing staff, but where the use of bedrails and Buxton chairs was routine.
Had I read The Lancet editorial at that time, I would probably have wholeheartedly agreed with it.
The debate has hardly become any less emotive in the years since. At the International Falls Prevention and Bone Health conference in 2007, the case for and against bedrail use was illustrated – albeit by speakers intending to provoke a reaction from the audience – by pictures of restrained and hooded prisoners in Guantanamo Bay.
It seems there is nothing quite like bedrails to provoke polarised views.
For most of my years in clinical practice, I worked with older people whose needs crossed mental health and acute hospital boundaries.
For this patient group, falls prevention was a constant concern, and balancing the risks of using or of not using bedrails was a constant challenge. So, as I moved into research, management and patient safety, the issues remained uppermost in my mind.
I had some formative experiences along the way. When I was a newly appointed ward sister, a patient in a neighbouring hospital died from bedrail entrapment. Such a distressing and lonely way to die; it was little wonder that my manager’s reaction was to send a porter to confiscate all our bedrails.
I found myself fighting to keep bedrails at least for those of my patients who were confused, restless, hoist-dependent hemiplegics on alternating pressure mattresses.
Analysing a batch of hospital bedrail policies influenced me, too. Some were excellent – but it would have been a brave nurse who dared to use bedrails in the hospital whose policy stated the devices were restraint, restraint without written consent was common assault, and this offence could be punished by a jail term of up to six months.
The aspect that made me saddest was that, for every 10 policies warning that bedrails could kill, there was barely one telling staff how they could avoid this happening.
I was also privileged to be allowed to survey bedrail use overnight in a number of hospitals, and to ask nursing staff about their reasons for using or not using them for individual patients (National Patient Safety Agency, 2007).
What was reassuring was that frontline nurses were usually making decisions based on their understanding of the wants and needs of individual patients.
However, some staff who had made perfectly sensible and justifiable decisions to use bedrails felt they had to apologise to me for making that decision.
Focus groups with patients (NPSA, 2007) also left me slightly embarrassed at how emotive the debate had become. Patients were pragmatic, and some appeared slightly amused by how seriously we took what they considered to be a minor aspect of care.
For all the experience and the emotion in the bedrail debate, what is the actual evidence? Professor David Oliver and I summarise the evidence in an In depth article.
Limited though this is, it suggests that both the ‘old school’ that advocates routine bedrail use and the ‘new school’ that advocates their abolition are equally wrong. Decisions on the risks and benefits of bedrail use can only be made case by case in partnership with individual patients.
Frances Healey is clinical reviewer for the National Patient Safety Agency
Anon (1984) Cotsides – protecting whom against what? Lancet; 2: 8399, 383–384.
National Patient Safety Agency (2007) Safer Practice Notice. Using Bedrails Safely and Effectively. London: NPSA.