Decision Making About the Use of Side Rails: The Role of Family Education
|Reprinted from the Winter
1998 (vol. VI, no. 1) and Spring 1998 (vol. VI, no. 2) issues of "HCFAs
National Restraint Reduction Newsletter" where it originally appeared in two parts.
It is available on the Health Care Financing Adminsitration's website at http://www.hcfa.gov/pubforms/rrnews.htm.
byJanet 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.
Why do families want side rails?
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.
How are nursing facilities educating families about side rail use?
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.
Is family education sufficient?
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
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.
Janet Myderis Director of Regulatory Systems at the American Health Care Association in Washington, DC. Stephen C. Biondi is Vice President of Quality management at Extendicare Health Services, Inc. in Milwaukee, WI.
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