Exploring the use of bedrails when used to support adults: A scoping review.

Patient and Public Involvement

This study was informed by concerns raised by family members and caregivers with a lived experience of bedrail use. In August 2023, the NPSA required that all individuals using bedrails in the UK be reviewed and associated risk assessments updated within six months.⁴ The review of existing bedrail prescriptions prompted significant concern among some stakeholders, including bedrail users and their families, regarding potential impact on care arrangements and personal autonomy.

Throughout this project, individuals who use bedrails, their representatives, and care partners were consulted. They confirmed the importance of this topic, noting that decisions regarding bedrail use may substantially affect 24-hour care planning and financial cost of care, equipment requirements, and perceived restrictions on personal liberty. Contributors also reported that decisions relating to bedrail use could be a source of emotional distress, further supporting the relevance and necessity of investigation.

Study design

A scoping review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guideline.¹⁰

Protocol

The review protocol was developed a priori and is available via the Open Science Framework (OSF) repository.¹¹

Search strategy

Informed by the findings of the previous literature review,² broad search terms were used to capture the diversity of literature on bedrail use. The S.P.I.D.E.R framework¹² was selected to support the development of an inclusive search strategy.

Inclusion

Sample: Adults

Phenomenon of Interest: Bedrails

Design: Studies where the primary focus was the use of bedrails. No restrictions were placed on publication date or language.

Evaluation: Any

Research Type: Any

Exclusion

Information sources

The following electronic databases were searched: MEDLINE and EMBASE (via OVID), EMCARE, Cochrane Library, CINAHL (via EBSCOhost), and the Bielefeld Academic Search Engine. Backward citation tracking of key documents was undertaken. Gray literature¹³ was identified using Google Scholar with the intention of capturing policy documents, professional guidance, audit reports, theses, and organisational publications not indexed in bibliographic databases. Key authors were contacted to request additional evidence where relevant material was not publicly available. The full search strategy, conducted on 6^th March 2024, is provided in the appendices hosted in the OSF repository.¹⁴ Searches were updated on 7^th January 2026.

Search terms

“Bed rail*” OR “bedrail*” OR “side rail*” OR “siderail*” OR “cot side*” OR “cotside*” AND “adult*” OR “older person*” OR “elderly” AND “community” OR “dwelling” OR “home” OR “care home” OR “residential home” OR “nursing home” OR “supported living” OR “hospice” OR “hospital” OR “unit*,”

Evidence selection

Database search results were exported to EndNote v.21, duplicates removed and records subsequently uploaded to Rayyan¹⁵ for screening. Title and abstract screening was conducted independently by two blinded reviewers using predefined eligibility criteria. Owing to time constraints, full-text screening was primarily undertaken by one reviewer, with a second reviewer independently screening 10% of full text articles to assess consistency and reliability. As agreement between reviewers was consistent, this proportion was maintained for the remainder of the screening process. Any discrepancies were resolved through discussion, and involvement of a third reviewer was not required.

Figure 1. PRISMA flow diagram of study selection, located in the OSF repository¹⁴ and reproduced from the 2020 PRISMA guidelines for systematic review reporting.¹⁶

Data extraction and synthesis

Data were extracted from included studies by one reviewer using an a priori data extraction table and checked for accuracy by a second reviewer. In keeping with scoping review methodology, formal quality appraisal of included studies was not undertaken. Given the heterogeneity of study designs and the exploratory, pragmatic nature of the evidence base, extracted data were synthesised narratively. Data extraction was iterative and involved ongoing familiarisation and refinement of analytic categories.

Table 1 Data extraction framework is located in the OSF repository.¹⁷

Clinical Drivers for Bedrail Use

Prescribers of bedrails appeared to draw on factors operating at both micro- and meso-levels when explaining clinical decisions regarding bedrail use. Several studies reported clinical rationales for bedrail use, most commonly falls prevention, prevention of bed exit attempts, use to support turning in bed, or at the request of the patient or family. These rationales were typically captured through staff surveys or audit tools. However, in many cases the underlying survey instruments were not reported, limiting insight into how these concepts were defined, understood, or operationalised. For example, studies citing prevention of bed exit attempts as a clinical rationale, did not report what underlying risks or contexts necessitated the use of bedrails.

Across the included literature, micro-level drivers were the most frequently cited and empirically examined. Several audit-based studies using multivariable analyses reported statistically significant associations between patient characteristics and the presence of bedrails. For example, in a large cross sectional, observational study conducted across seven UK NHS trusts (n = 1092), patients described as immobile were substantially more likely to have bedrails in place when compared with those described as independently mobile (adjusted odds ratio (AOR) 62.5, 95% confidence interval (CI) 27.4 to 142.8), indicating a strong association between immobility and bedrail use, despite the uncertainty in the magnitude of the effect.²¹

In addition to immobility, cognitive status was also associated with bedrail use in UK based audit studies. Healey et al. reported that patients described as very confused were significantly more likely to have full bedrails raised than those described as not confused (AOR 7.8, 95% CI 3.7 to 16.5).²¹ Similarly, Hignett et al. identified an increased likelihood of bedrail use among patients described as very confused compared with those described as not confused (AOR 2.62, 95% CI 1.68 to 4.09).²² These findings indicate a consistent association between reported confusion and bedrail use across UK inpatient settings.

Several older studies identified meso-level drivers of bedrail use, including organisational policy, professional culture, and organisational risk management in response to concerns regarding litigation. In particular, some U.S. based literature described bedrail use as culturally accepted or routine practice for new admissions, reflecting established organisational norms rather than individualised clinical assessment.^35,38

Few studies explicitly examined macro-level drivers influencing bedrail use, such as national policy, regulatory frameworks or broader political and legal contexts. Where macro-levels were discussed, this was largely confirmed to opinion pieces concerning the limited national or professional guidance, or evidence based frameworks.

Several studies and reports referenced potential alternatives to bedrails or factors that should be considered prior to prescribing, such as environmental modification, enhanced supervision, floor beds, or individual risk assessment that may include medication review and continence care plans. However, these alternatives were discussed descriptively rather than evaluated empirically. No studies were identified that compared bedrails with alternative interventions in terms of effectiveness, safety, or patient outcomes. As a result, suggestions regarding alternatives were largely speculative and not supported by comparative or robust evidence.

Prevalence of Use

Prevalence of bedrail use was most frequently captured using snapshot audit-based studies, defined as observational reviews of occupied inpatient beds, conducted at a single point in time, in hospital or long-term care homes. Many audits explicitly excluded specialist clinical areas such as high dependency units, critical care, cardiac units, emergency care environments, and maternity units, thereby limiting applicability of findings to these settings. Data were reported as a binary outcome of either bedrails in use (raised or partially raised) or not in use and findings presented as a percentage of total occupied beds using bedrails. Across UK and Irish acute inpatient wards, full or partial raised bedrails were observed to be raised in approximately 16% to 52% of total occupied beds.^18,20–23

Variation in bedrail use was reported both within and between organisations. For example, Noore et al. identified a lower prevalence of raised bedrails in a geriatric ward when compared with other wards within the same district general hospital (7% occupied beds versus 19% in other wards).¹⁸ Healey et al. found significant variation in bedrail use across seven NHS Trusts, with no clear relationship between the presence or content of bedrail policy and observed bedrail use. No interaction effects were detected between organisational bedrail use and patient age, mobility, confusion, bed type, or mattress type. After adjustment for these variables, the likelihood of full bedrails being raised in one NHS organisation was ten times more likely when compared to another.²¹

Exploring the Impact of Bedrails

Several studies examined the impact of interventions intended to reduce bedrail use on the overall number of falls that occurred within the patient bedspace. These studies were predominately observational and included before-and-after designs implemented within hospital inpatient or long-term care settings and falls outcomes were captured through internal incident reporting systems. Across these studies, changes in bedrail use were not consistently associated with a significant change in falls rates. Some studies reported no change in the number of falls^34,35 whilst others had mixed findings.³⁶

Authors frequently acknowledged methodological limitations, including reliance on incident report data, limited control for confounding variables, and variability in how falls were defined and recorded. Across the before-and-after studies, exposure to bedrails was inconsistently reported or not reported at an individual patient level. For example, it was not possible to identify if a person who experienced a fall in the before or after period of the studies were using bedrails at the time of the fall.³⁵

Reports of harm associated with bedrail use were identified primarily through reviews of organisational incident reports³⁸ and reports submitted to national regulatory or governing bodies.^{1,39,40,43–46} These sources described adverse events including limb entrapment, asphyxiation, and death occurring across a range of care settings. Several authors noted limitations in the available data, including incomplete reporting, lack of independent verification, and absence of denominator data, limiting estimation of incidence or risk. In many cases, contributory factors such as equipment incompatibility, incorrect assembly, use of mattress overlays (that increase the height of the mattress in relation to the height of the bedrails), or inadequate patient monitoring were described.

Evidence relating to harm associated with bedrail use was also identified in a review of NHS clinical negligence claims relating to inpatient falls. Between 1995 to 2006, bedrails were listed as the primary cause of harm in 11.9% of claims, while the absence of bedrails was cited in 10.6% of claims.⁷ All claims were settled out of court and no legal rulings establishing liability or causation were available. The mean payment per claim was £12945, with authors noting that difficulties in establishing causation were compounded by patient frailty, multiple comorbidities, and limitations in documentation.⁷

Experience of the User

Evidence relating to the experience of bedrail use from the perspective of patients and their families was limited and predominantly descriptive in nature. Where reported, some patients expressed a preference for bedrails, describing feelings of safety. In several studies, family request was cited as clinical rationale for bedrail use, although the context and basis of those preferences were not explored. Family members and care partners were also reported to influence bedrail use, particularly in long-term care and inpatient settings, where bedrails were perceived as contributing to patient safety. Overall, reporting was indirect, relying on staff perceptions of clinical rationale rather than first-hand accounts.

Experiences of bedrail reduction were also reported indirectly through descriptions of implementation challenges in before-and-after studies. Authors described reluctance and scepticism among staff, patients, and families when attempts were made to reduce bedrail use, with particular emphasis on the time and effort required to engage stakeholders on the topic, conduct individual assessments, and discuss alternatives to bedrails.³⁵ In one study conducted across three US nursing homes, routine use of raised bedrails for all new admissions persisted despite multidisciplinary involvement, updated assessments, and targeted strategies such as ‘rail rounds,’ reflecting entrenched practices and resistance to change.³⁶

Ethical considerations and balance of imperatives

Ethical considerations relating to bedrail use were discussed in several studies, most often in narrative or opinion-based literature rather than empirical investigations. Authors commonly describe ethical tensions between the perceived need to maintain patient safety, particularly in relation to falls prevention, and the preservation of patient autonomy, dignity, and freedom of movement in pursuit of meaningful occupations of time. Bedrails were inconsistently described as both a supportive device and a restrictive intervention, with few studies providing explicit criteria for distinguishing between these interpretations.

Concerns regarding restraint and restriction in liberty were raised in a number of sources, particularly within UK based literature, where bedrails were explicitly described as inappropriate when used to restrict movement rather than to mitigate specific falls risk.² Ethical concepts were often described implicitly or presented as opinions expressing concern that ethical considerations should form part of a bedrail assessment. Overall, whilst the literature highlighted ethical complexity and ambiguity surrounding bedrail use, limited empirical insight into how competing ethical imperatives were balanced in clinical practice was identified.

Statement of principal findings

This scoping review aimed to identify and map the literature relating to the use of bedrails to support adults. A heterogeneous and predominantly descriptive evidence base relating to the use of bedrails across inpatient and long-term care settings was identified, originating primarily from the UK and the US. Across studies, clinical rationales for bedrail use, such as falls prevention or prevention of bed exit, were frequently reported. The majority of evidence was developed at the micro-level, where audit-based studies demonstrated strong associations between specific patient characteristics, particularly immobility, and the presence of bedrails. A consistent association was also identified in UK inpatient settings between bedrail use and patients described as very confused. Prevalence of bedrail use varied widely between and within organisations, with variation observed irrespective of the presence of local bedrail policy.

Strengths and weaknesses of the study

This scoping review has several methodological limitations. Due to time constraints, full-text screening was primarily conducted by a single reviewer, with ten percent of studies independently screened by a second. Data extraction was undertaken by one reviewer with verification by a second rather than duplicate extraction on a subset of studies. These approaches are consistent with a pragmatic scoping review methodology but may have increased the potential for selection or extraction bias. An additional limitation is the inconsistent framing of bedrails within international literature, where bedrails are variably discussed as a falls prevention device or as a restrictive intervention. This lack of conceptual clarity may have affected synthesis, as authors were not always addressing the same underlying purpose or mechanism of use, despite employing the same terminology. A key strength of this review is the integration of patient and public involvement, which informed the focus of the inquiry and ensured that the review addressed relevant issues to those directly affected by bedrail use and prescribing decisions.

The findings of this scoping review are consistent with those reported in 2007 by Healey et al. which similarly identified a limited body of empirical research examining bedrail use, predominantly within inpatient and long-term care settings.² Challenges in advancing research in this area have been recognised for several decades. As early as 1983, Rubenstein et al. highlighted the need for a randomised controlled trial to evaluate bedrail use but concluded that such a study would be difficult, if not impracticable to design and implement.³⁸ This ongoing methodological challenge may partly contextualise the continued reliance on observational and descriptive approaches within the literature.

Possible mechanisms and implications for clinicians or policymakers

The findings of this review suggest that bedrails may function, in part, as a response to perceived falls risk in situations where patients are viewed as vulnerable or unpredictable. Decisions regarding bedrail use are frequently made in the context of limited empirical evidence and in the absence of clearly articulated or defined mechanisms of action. While patient characteristics such as immobility were strongly associated with bedrail use, these associations alone do not explain the clinical reasoning underpinning individual prescribing decisions. Across the literature, rationales for bedrail use were often broad, variably defined, and inconsistently operationalised, with limited links to measurable outcomes. This disconnect between empirically observed patterns of use and the rationales offered to justify them underscores the complexity of decision-making in this area, where clinicians are required to balance the potential for harm associated with bedrails against perceived benefits in the face of uncertainty.

When making decisions about bedrail use and in the absence of robust evidence or explicit decision-making frameworks, clinicians appear to rely on heuristics, risk perceptions, and contextual factors rather than organisational policy. Reports of difficulty implementing bedrail reduction strategies suggest that entrenched local norms of practice, staff and family expectations, and perceptions of risk exert a stronger influence on practice than written guidance. In this context, bedrail use appears to be sustained by local cultures of care and defensive practice, contributing to persistent variation despite awareness of potential harm. These patterns highlight the challenges inherent in individualised decision-making where risk is difficult to assess, articulate, or quantify, and where the intended purpose of bedrail use, its mechanism of action, and associated outcomes remain uncertain.

Ethical and medico-legal uncertainty was also evident across the literature. Evidence from NHS negligence claims indicates that bedrails are cited both in cases when they were used and when they were not, suggesting that they are perceived simultaneously as both protective and harmful devices. This ambiguity is reflected in a 2025 Delphi consensus study examining falls prevention strategies in hospital settings, which concluded that bedrails could not be recommended as a reference standard for falls prevention due to concerns regarding patient safety and routine use.⁴⁸ This conclusion was informed by the 2022 World Guidelines for Falls Prevention and Management for Older Adults, which explicitly identify bedrails as a form of restraint.⁴⁹ The framing of bedrails as both a falls prevention device and a restrictive intervention illustrates the ethical and clinical complexity faced by clinicians when considering their use, with implications not only for clinical accountability but also for patients and families who may experience uncertainty and distress regardless of whether bedrails are used or withheld.

Unanswered questions and future research

A pragmatic, realist evaluation of bedrail use across acute inpatient, long-term care, and home settings may offer a more appropriate approach to understanding how context, mechanisms, and outcomes interact within different care environments. In addition, qualitative research examining clinical decision-making regarding bedrail prescription could provide valuable insight into how organisational policy, cultural norms of practice, contextual variables and ethical, and medico-legal concerns are balanced in situations characterised by uncertainty. Such work could help inform future practice and guide the development of more context-sensitive research.

Ethics and consent

Ethical approval and consent were not required.