by Janet A. Myder and Stephen C. Biondi

In the current environment of restraint reduction, the use of bed side rails increasingly is being questioned. No longer are side rails viewed as inconsequential attachments to a patient's or resident's bed.

Nursing facilities that are attempting to reduce and find alternatives to the use of restraints are evaluating how and why they use side rails. Federal policy which considers side rails to be restraining devices under certain circumstances encourages this evaluation. As with any course of care, a nursing facility's decisions about whether or not to use side rails may be difficult and must be made on an individual resident basis. When families request the use of side rails, these decisions become more complex.

This article describes the challenges that facilities encounter when determining the proper use of side rails. In designing an approach that meets residents' individualized quality of care and quality of life needs, facilities try to balance the promotion of residents' rights, choice and dignity, their response to families' requests, and the fulfillment of their responsibilities to residents.

The majority of individuals in nursing facilities are admitted or readmitted after a hospitalization. Residents and their families often form their attitudes toward side rails through their hospital experiences. In the hospital, staff use side rails for patients without the limitations of specific federal regulation and for reasons not allowed by statute in nursing facilities. The differences between federal rules that are imposed on hospitals and those imposed on nursing facilities are a source of confusion to family members and often lead to conflict between families and the nursing facility. Family members have difficulty understanding why the facility cannot use side rails for the same resident in the same way as in the hospital.

Whether or not the resident was hospitalized, families tend to expect that side rails will be used out of concern for the safety of their family members. They request the use of side rails, not realizing initially that the rules and expectations imposed on nursing facilities do not support the routine use of side rails. These situations add to the difficulties that many facilities encounter in convincing families that side rail use may not be the best approach for a particular resident.

An informal survey of American Health Care Association members revealed numerous approaches to family education on restraints use which also address side rails. For example:

1. An interdisciplinary team approach to restraint reduction is used. The team involves families in decision making and meets with them on an ongoing basis.

2. A defined policy on restraints use or non use is established. Staff discuss the policy with families of potential residents when they visit the facility. It is given, in writing, to families and residents upon admission, explained, and discussed with them. Staff review the policy if the physician orders a restraint or the family requests the use of restraints.

3. The facility uses federal law and regulations which address restraints to assist in family education. Staff discuss the law and regulations with families and give copies to family members. Facility staff meet with families as a group to discuss the regulations and how they are implemented in the facility.

4. The facility encourages and assists the family to be involved with the resident to help when restraint reduction is being implemented.

5. The facility teaches families and staff that restraints use, accepted for years both by health professionals and by families, is now considered potentially harmful or replaceable with more positive and therapeutic alternatives.

6. The facility trains staff in ways to work with families who are resistant to removing or not using restraints and also directs education and "one-on-one" efforts to families.

Federal policy makers, consumer advocates, and nursing facility personnel have assumed that educating families and residents about federal requirements and the potential danger of restraints would address families' misconceptions, reduce family pressure on facilities, and stimulate progress toward limited restraint use. This has not necessarily been the case. Indeed, family education is an essential component of a facility's restraints use policy. However, family education alone will not reduce conflicts about side rails use. It is only one part of a systematic approach that the facility can use to identify the needs of individual residents and provide them with the most effective care. In addition, the facility is only one of a number of individuals and groups affecting the health and well being of nursing facility residents. Others include attending physicians, medical directors, health practitioners and providers such as hospitals. They should be part of any national approach to reduce unnecessary restraints use.

What else is needed?

Implementing a number of approaches to the use of side rails helps to foster decision making that is in the best interest of residents' care needs. These approaches also help to assure the protection of residents' right to make choices, control their environment, and live in dignity. Below are examples of approaches that can be designed and implemented with the coordination and cooperation of the Health Care Financing Administration (HCFA), state survey agencies, nursing facility providers, and residents' representatives.

1. Focus on risk assessment - - Safety is a driving concern that leads families to request, even demand restraints. Therefore, greater attention should be placed on a systematic approach which includes risk assessment, investigating incidents and preventing falls in an effort to eliminate unnecessary use of side rails as restraints.
2. Recognize that some risk must be accepted or assumed - - Does achieving "highest practicable" for a resident mean eliminating risk? Residents do not enter a protective bubble when they are admitted to a nursing facility. They enter a place that must assess residents' risk and address identified risks through an individualized care plan. This system helps residents to achieve the "highest practicable" level of functioning that their conditions allow. Getting there takes time. The approach may contain unpredictable factors and outcomes, and it sometimes necessitates trial and error.
3. Develop clear policy guidance - - Facilities, families and residents need direction from HCFA regarding side rail use as it affects residents' rights and residents' choice. A clearly defined policy also helps surveyors to make decisions about facility compliance with regulations and answer questions such as: If a competent resident chooses to use a side rail, is it a restraint? Is a resident's right to choose a treatment different from the right to refuse a treatment? If a family member with legal decision making authority for the resident requests that a side rail be used, is it a restraint?
4. Provide specific education to families and residents about the rules - - Medicare beneficiaries and Medicaid recipients and their families need written information from these programs to help clarify their expectations of side rail and restraint policies in hospitals, nursing facilities and other settings.
5. Create uniform definitions of terms - - A uniform set of definitions helps to reduce families' misunderstanding and unrealistic expectations about side rail use as well as facilities' and surveyors' confusion about regulatory compliance. Clearly defined terms such as medical symptoms and situations which cause side rails to be restraints are needed. HCFA is developing such guidance.
6. Educate physicians - - Many families turn to the residents' physicians for support when the facility and family are not in agreement over whether a side rail is necessary. In response, the physician may prescribe side rails contrary to the regulations. Physicians need information about the law and regulations, alternatives to restraints, and the potential risks to the resident if restraints are used unnecessarily. This information fosters not only the doctors' understanding of side rail policy, but also families' understanding.
7. Develop realistic alternatives to side rails - - When alternatives to side rails are considered, their potential effects on residents' dignity must be balanced against the side rails' potential risk to the resident. Using alternatives such as very low beds or mats on the floor may not be desirable options for all residents. Some practitioners and residents consider them to be undignified. Mats on the floor may also pose a risk of tripping the resident who tries to walk, and they potentially jeopardize infection control and staff work place safety.
8. Seek design changes - - Manufacturers' modifications to the design of side rails and bed/mattress/rail combinations have the potential to make this equipment safer for residents' use. The Safe Medical Devices Act of 1990 encourages manufacturers to work with medical device equipment users to modify or change device designs in an effort to make their application safer for residents and staff alike. The Food and Drug Administration (FDA) should encourage such efforts between manufacturers and providers to design safer bed side rails that would eliminate any potentially unsafe conditions for residents. HCFA should assist providers in alerting the FDA to the need for side rails and bed/mattress/rail combinations redesign.
   

Whatever policy or practice changes are designed and implemented, the paramount elements in the approaches toward side rail use should be preservation of the resident's right to make treatment decisions and the best interest of the resident's health, safety and dignity.