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

Bedrails, Adults, Hospital, Community, Own Home, Nursing Home, Clinical Drivers, Harm, Falls Prevention, Risk, Ethics, UK, US. ALL Metrics - Views Downloads How to cite this article Farrell V, Hall A and Goodwin V. Exploring the use of bedrails when used to support adults: A scoping review. [version 1; peer review: 1 approved with reservations]. NIHR Open Res 2025, 5:22 (https://doi.org/10.3310/nihropenres.13829.1) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente Select a format first ▬ ✚ Systematic Review [version 1; peer review: 1 approved with reservations] PUBLISHED 10 Mar 2025 Author details Author details 1 Cornwall Partnership NHS Foundation Trust, Bodmin, England, UK 2 Faculty of Health and Life Sciences, University of Exeter, Exeter, UK 2 Faculty of Health and Life Sciences, University of Exeter, Exeter, UK Vicky Farrell Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Resources, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Resources, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Abigail Hall Roles: Conceptualization, Formal Analysis, Funding Acquisition, Investigation, Methodology, Resources, Software, Supervision, Validation, Visualization, Writing – Review & Editing Roles: Conceptualization, Formal Analysis, Funding Acquisition, Investigation, Methodology, Resources, Software, Supervision, Validation, Visualization, Writing – Review & Editing Victoria Goodwin Roles: Conceptualization, Software, Supervision, Writing – Review & Editing Roles: Conceptualization, Software, Supervision, Writing – Review & Editing OPEN PEER REVIEW REVIEWER STATUS In the UK, concerns regarding the safe use of bedrails, especially in nursing homes and a person’s own home, led to a National Patient Safety Alert in August 2023. To identify and map literature relating to bedrail use in hospital and community settings when used to support adults and identify future areas of research. A scoping review of the literature was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses Scoping Review guidelines. The search was conducted in MEDLINE, EMBASE, EMCARE, COCHRANE, BASE, CINAHL, and Google Scholar. Two reviewers independently conducted title and abstract screening. One reviewer completed full text screening, with a random 10% screened by the second. Discussions between reviewers resolved any queries regarding inclusion. The primary reviewer completed extraction. A total of 33 papers were included. Bedrails are primarily used as a falls prevention device. They are not inherently dangerous when used safely and appropriately, are compatible with the bed frame and bed accessories, are fitted correctly, and are well maintained. However, the use of bedrails as a paternalistic tool to reduce the care burden by introducing physical restrictions on an individual is concerning. In the UK, decisions to prescribe appear to be influenced by local culture and practice but perhaps demonstrates inadequate legal literacy in this area. There is concern that the use of bedrails is increasing with increasing patient dependency and developments in bed technology. There is an absence of empirical data to support bedrails as a falls prevention device. Additionally, there is a dearth of evidence reporting the opinions of users or enquiry examining bedrail use in settings beyond hospitals and nursing homes. Clinicians are advised to consider bedrail prescriptions with a sense of responsibility and inquisitive enquiry to support both ethical and lawful bedrail prescription. In 2023, the UK Government released a National Patient Safety Alert regarding the use of bedrails (also known as cotsides) following reports of death and injury as a result of their use. This study aimed to identify what is known about the use of bedrails and what future research is required to improve patient safety. The researchers conducted a comprehensive review of the scientific literature following established guidelines for systematic reviews. The review included 33 papers and found that none of the papers investigated whether bedrails worked to reduce the likelihood of falling out of bed but identified that they are used widely in healthcare settings. Additionally, there is little research on the opinions of bedrail users or reports on their use in a person’s own home. When used correctly, they do not appear to be dangerous. However, there is concern that bedrails are sometimes used to reduce the workload of caregivers by physically restricting an individual to their bed. In the UK, the decision to use bedrails seems to be influenced by local practices but suggests a lack of legal understanding in this area of law. There is also a concern that the use of bedrails is increasing as patient needs grow and bed technology advances. Healthcare professionals are encouraged to prescribe bedrails responsibly and thoughtfully, considering both the ethical and legal aspects. Bedrails, Adults, Hospital, Community, Own Home, Nursing Home, Clinical Drivers, Harm, Falls Prevention, Risk, Ethics, UK, US. Corresponding Author(s) Vicky Farrell ([email protected]) Grant information: This project is funded by the National Institute for Health and Care Research (NIHR) under its [‘Research for Patient Benefit (RfPB) Programme’ (Grant Reference Number PB-PG-NIHR305094)]. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Copyright: © 2025 Farrell V et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Farrell V, Hall A and Goodwin V. Exploring the use of bedrails when used to support adults: A scoping review. [version 1; peer review: 1 approved with reservations]. NIHR Open Res 2025, 5:22 (https://doi.org/10.3310/nihropenres.13829.1) First published: 10 Mar 2025, 5:22 (https://doi.org/10.3310/nihropenres.13829.1) Latest published: 16 Apr 2026, 5:22 (https://doi.org/10.3310/nihropenres.13829.3) The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. There is a newer version of this article available. of this article available. Bedrails form a barrier along the edge of a bed, and are available in various designs, lengths, and materials. In the United Kingdom, when bedrails are prescribed by a clinician with a ‘clear medical purpose,’ they are classified as a medical device1. The purpose of prescribing bedrails is to support adults by reducing the likelihood of falls from bed1 due to a slip, slide, or roll2. For example, when a person moves from a double to single bed3, performs functional tasks with the head of the bed elevated (especially if on a dynamic air mattress), or when bedrails are recommended by the manufacturers of moving and handling products. In the UK, bedrails must never be used as a restraint1, an unauthorized restriction in freedom of liberty1,4, or as a moving and handling aid, as they are not designed to be used as such2. In August 2023, the UK Medicines and Healthcare products Regulatory Agency (MHRA) issued a National Patient Safety Alert (NatPSA) concerning the risk of death from entrapment or entanglement in bedrails, particularly when used in nursing homes or a patient’s own home5. From 1st January 2018 to 31st December 2022, the MHRA received 18 reports of deaths related to bedrails and associated equipment and 54 reports of serious injuries1. In the UK, both the use of bedrails and the decision not to prescribe bedrails have led to civil and clinical negligence claims6–8. This issue is further complicated by the difficulty in learning from events due to inconsistent or insufficient documentation related to falls, such as incident reports, root cause analysis, patient records, and serious case reviews8. In 2007, the National Patient Safety Agency (NPSA), now part of NHS England, conducted a systematic literature review of bedrail use in hospitals. Most of the thirty-two included studies were ‘not scientific’ and ‘too small’ to produce statistically significant results. These papers included single case studies and anecdotal accounts. The review found that many papers on bedrails were opinion pieces and concluded that ‘there are no specific randomized controlled trials; therefore, we have no robust evidence’ regarding the use of bedrails2. In 2023, the NatPSA required every UK organisation involved in bedrail use to review and update all bedrail policies and procedures5. On a global platform, access to safe and effective medical devices is one of the six leadership priorities of the World Health Organisation9. It appeared timely to complete an up-to-date scoping review of the use of bedrails. This study was designed to address concerns raised by family members and caregivers with a lived experience of bedrail use. In August 2023, the NatPSA requested that within 6 months, every person using bedrails in the UK must be reviewed and risk assessments updated5. Reviewing legacy bedrail prescriptions has elicited strong and divisive opinions across stakeholders, leading to the potential for legal action and some users of bedrails have approached their local MP in protest at the reviews. Throughout this project, bedrail users, their representatives, and carers were consulted. They confirm that this is an important topic for investigation, as the consequence of prescribing or not prescribing bedrails has a significant impact on what a 24-hour care plan may look like, what equipment is needed, the financial cost of the plan, and the varying effect on a person’s freedom of liberty. They also confirmed the decision to prescribe or not prescribe bedrails could be a source of emotional distress, further adding to the validity of pursuing this area of concern. A scoping review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA- ScR) guidelines10. Based on the results of the NPSA literature review2, the search terms were broad and S.P.I.D.E.R12 was selected to develop an inclusive search strategy. Inclusion Sample: Adults Phenomenon of Interest: Bedrails Design: The primary focus of the study was the use of bedrails. There were no limitations to date or language. Evaluation: Any Research Type: Any Exclusion The following bibliographic databases were searched: MEDLINE, EMBASE, EMCARE, COCHRANE, CINAHL, and Bielefeld Academic Search Engine. Backward citation tracking of significant documents was performed. Gray literature13 was sourced from Google Scholar. Key author(s) were contacted to provide evidence where it was not publicly available. The search strategy dated March 6, 2024, is available in the appendices, located in the Open Science Framework repository14. “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*.” Database search results were exported to EndNote v.21 and duplicates removed. The results were then uploaded to Rayyan, where additional duplicates were identified and removed. Title and abstract screening were performed using Rayyan, and papers were assessed according to eligibility criteria by two independent, blinded reviewers. Owing to time constraints, the first reviewer conducted full-text screening. To ensure the accuracy of the screening process, a second reviewer reviewed 10% of the papers. Because the screening results were consistent, a 10% review rate was maintained. Any differences in opinions regarding the inclusion of papers were resolved through discussion, and a third reviewer was not required. Data were extracted from the papers by a single reviewer and checked by a second reviewer. This review did not include quality appraisal of the papers. Due to scarcity of scientific enquiry in this topic, data assumptions and simplification were not required. The a priori data extraction table is located in the protocol10; however, data extraction was iterative and involved continuous analysis. Extracted data were reported narratively. Thirty-three papers were included in the review (Figure 1). Publication dates ranged from 1983 to 2024 and primarily originated from inpatient hospital settings in the UK and United States. Most of the published papers were reports or opinion pieces made by those working in the care of older adults. Prescribers appear to consider factors from the micro and meso levels of available information, with a suggestion that macro-level influences are sometimes missing in the decision-making examples captured in the included papers15–19. Micro: The patient and their immediate environment and context, as viewed through the prescriber’s personal biases. Meso: The knowledge, skill, and ethos of ward staff regarding legal restraint, safe moving and handling, goal setting, risk management, rehabilitation, and the culture of the organisation. Macro: Awareness of the laws, statutory regulations, and professional codes of conduct that govern practice. Both the clinical drivers to prescribe bedrails and the factors that cause incidents of harm or death from bedrails share a similar number of key features (Figure 2). The primary clinical driver across all the studies was falls prevention (Table 1). Assisting bed mobility (by allowing the patient to pull on the rails to support repositioning) has also been reported, although bedrails are not designed for this purpose1,2. In three of the five snapshot audits16,18,19, staff reported bedrail use as a physical restraint, with the aim of preventing patients from leaving their beds. None of the audits included methodologies to explain how staff opinions were collected, nor did they include evidence of compliance with the Mental Capacity Act (2005) (or equivalent law if within the UK but outside England and Wales). Further clinical drivers for bedrail prescription were identified (Figure 2), such as patient characteristics17–19,24, other equipment in use17,19, availability of a clear view of the patient, and sufficient staffing to enable watchful observation40. Healey et al. found that patients described as ‘unable to mobilise at all’ had the highest adjusted odds ratio and were 62.5 times more likely to have bedrails raised than patients able to walk (CI 95%). Patients described as confused or on alternating pressure mattresses and electric profiling beds also had significantly higher adjusted odds ratios for bedrail use than patients on static mattresses and beds17. Bedrail use in the US is defined by a consensus between law and medicine, rather than empirically driven intervention40. In the US, bedrails are routinely used either by mandates or fear of litigation25,26,28,36,40. It is also important to note that in the US, bed restraint products and beds encased in net cages are licensed and in use41. Therefore, the intent to prescribe bedrails in the US is in sharp contrast to that in the UK. The prevalence of bedrail use reported in audits varied between 16% and 52% of total occupied, acute inpatient beds15–19. Noore identified that patients in the geriatric ward of the district general hospital audited were significantly less likely to have raised bedrails than those in other wards in the same hospital (7% occupied beds versus 19% in other wards)15. This suggests that knowledge and experience impact the decision to prescribe bedrails. Healey et al. found significant differences in bedrail use across seven NHS Trusts, with a lack of correlation between bedrail policy and bedrail use. No interaction effects were detected between an organisations’ levels of bedrail use and age, mobility, confusion, bed, or mattress type, yet the likelihood of full bedrails being raised in organisation B was more than 10 times that in organisation A17. This adds to the suggestion that bedrail use is driven by more than surface-level opinions captured by the staff surveys. The authors also expressed concerns that bedrail use is increasing over time, partly due to advancements in bed technology2,18,19 and increasing patient dependency2. An anonymous commentary published in the Lancet in 1984 suggested that it is conceivable that all falls could be prevented if patients were sedated and encased in fortified beds. However, care including rehabilitation is incompatible with total falls prevention25. This sentiment was echoed in 2002 by Oliver who suggested that bedrail prescriptions should incorporate a balanced, biomedical ethical decision encompassing respect for patient autonomy (the right to choose to pursue meaningful occupations of time despite the falls risk), paternalism (we will not let you fall), beneficence (to do good for the whole person’s health and wellbeing), non-maleficence (to do no harm, either intentionally or unintentionally, that is, to act unlawfully, entrapment, or asphyxiation in bedrails), and justice (fair access to resources)6. Bedrails are not inherently dangerous but are open to misuse by clinicians and may lead to rare incidences of harm1,2,5,7,36–38,42–44 through ill-advised clinical reasoning1,2,3,6,22–24,30,39,45,46, using bedrails beyond their intended scope, poor bedrail design21,27,44, poorly fitting bedrails, incompatibility of products, and limited learning from events affected by data quality issues33,34,36–38,43. In the US, there are an average of 20 deaths per year caused by bedrails, mainly in nursing homes. In the UK, there are an average of three deaths per year in care homes and patients’ own homes, attributed to bedrails2. Deaths caused by bed rails in UK hospitals are very rare, with three reports in seven years by the MHRA2. In the UK, the MHRA identifies bedrail design, patient selection, and setting—whether in a care home or a person’s own home—as key contributors to death or harm involving bedrails1. It has been reported that American manufacturers of bedrails often attribute deaths caused by their use to improper clinical monitoring or decision-making42. Similarly, in the UK, Healey advised that the risk of fatal bedrail entrapment in hospitals is not random and can be reduced by following the advice on using bedrails safely2. If harm caused by bedrails in the UK is partly predictable through choices and actions made by organisations (Figure 2), this does not appear to be demonstrated in a review of NHS clinical negligence claims regarding falls7. Between 1995–2006, bedrails were listed as the primary cause of harm in 11.9% of claims regarding inpatient falls, and the absence of bedrails in 10.6% of claims. All claims were settled out of court; therefore, no legal rulings establishing liability or causation of injury were available. The mean payment for each claim was £12945. Oliver et al. suggests that the low payment reflects difficulty in establishing causation secondary to frailty, multiple comorbidities, and poor documentation7. Clinical negligence claims, when bed rails were used and bed rails were not used, suggest that the decision to prescribe is of equal importance as the decision not to prescribe. Poor documentation has also been identified in reviews of incident reports7,36,38,42,43. Most incident reports did not specify the types of bedrails used, their compatibility with the bed frame and mattress, their maintenance status, or whether they were correctly fitted. They did not report compliance with the best-interest process for those who were unable to consent to their use. This reveals that organisations may not be able to fully learn from events. Four before-and-after studies were identified which examined the impact of bedrail reduction strategies in nursing homes and inpatient hospital settings in the US and New Zealand32–35. Researchers approached bedrails as a negative device and strategized to reduce their use by intervening at the micro and meso levels. The authors failed to include details in their methodologies, which demonstrated acknowledgement of or control over the variables. Adherence to strategies introduced to reduce bedrail use was not reported, yet all authors presented their results as a direct outcome of intervention. Their results cannot be interpreted from the perspective of UK clinical practice because the clinical drivers and intent to use bedrails are different (both the US and New Zealand permit the lawful use of physical bed restraints). However, the results offer some insight into behaviour change involving bedrails. Si et al. reported that despite best efforts to reduce bedrail use, they were met with reluctance and scepticism. It was challenging and time-consuming to educate wary staff and families, conduct assessments, and discuss alternatives to bedrails33. Hoffman et al. studied bedrail use in three US nursing homes and despite efforts from a multidisciplinary team, updated assessments, persuasion, and strategies like ‘rail rounds,’ they could not change the practice of using raised bedrails for all new admissions34. Authors have speculated how a person might feel when using bedrails, but only Healey, on behalf of the NPSA, has asked. Healey conducted two focus groups using opportunistic sampling, with participants attending an outpatient clinic following a recent hospital admission. The groups were unstructured but centred on key themes. Group One consisted of people with dementia, depression, or anxiety from South England, while Group Two included Black, Asian, and minority ethnicity stroke survivors from North England45. All patients felt that the use of bedrails should be based on their wishes and concerns about falling out of bed, even if staff disagreed. Bedrails were considered helpful, especially for those accustomed to a double bed at home. No one reported being given bedrails against their wishes, nor did they view them as reducing their independence or dignity. The participants suggested that bedrails could have softer finishes and come in different sizes45. Capezuti et al. suggested that by addressing patient characteristics that may lead to bedrail use with alternative, less restrictive practice, intervention can focus on patient safety while promoting humane, dignified, and ethical care39 (Figure 3). Many authors have reported alternatives to bedrails, including: Consider alternative equipment Consider the patient Consider operational practice which reduces bedrail use This scoping review aimed to identify literature related to the use of bedrails in hospital and community settings when used to support adults. Thirty-three papers were identified, with the majority originating from hospitals or nursing home settings in the UK or US in the 2000s. No RCTs were found that investigated the efficacy of bedrails as falls prevention device. Only one qualitative study was identified which was part of a published report. It appears that, soon after their origin in healthcare, bedrails have the potential to be used beyond their intended purpose. Initially designed as a beneficial medical device to prevent an accidental fall from the bed, they evolved in some cases, into a paternalistic device. This shift imposes the will of the prescriber to keep a person in bed and perhaps alleviate the care burden an individual may present. The reported use of bedrails to restrain adults in UK and Irish hospitals may indicate some acceptance, even complacency, of this circumstance. This review had some methodological limitations. Secondary to time constraints only ten percent of the full-text screening was completed by two reviewers. Data extraction was performed by one reviewer and verified by a second reviewer (instead of conducting a portion of the data extraction). The strength of this review is that PPI has formed the foundation of inquiry. This study has been challenged by the varying uses of the term ‘restraint.’ Its meaning appears to change across cultures, contexts and policies. In the US, bedrails are often used unconditionally26,28,33,36 and are permitted as part of a range of physical restraints to prevent bed exit2,41. In contrast, in the UK, the results did not demonstrate evidence of automatic bedrail use, where the use of bedrails as a restraint has the potential to be unlawful. Consequently, comparing the results is difficult because the cohorts of fallers identified in each study differ, making any comparison challenging in an already heterogeneous population. These results were similar to those reported by Healey et al.2. However, this review introduces the novel concept of identifying evidence regarding bedrail use in a person’s own home, despite the absence of such evidence. Challenges in advancing research in this area have been evident for several years. In 1983, Rubenstein et al. proposed the need for a blinded RCT to evaluate the impact of bedrails but suggested that designing such a study presented significant difficulties that may be insurmountable36. In a 2024 report, the UK Parliament stated that, over the past two years, the number of patients waiting over 12 hours for admission to NHS hospitals has increased substantially47. Bed occupancy rates have increased48 and national ambulance response times are outside expectations47. These facts inevitably increase the pressure on patient flow and compels clinicians to expedite discharges. Frengley asked readers to consider the image of an older adult in a bed with bedrails up, suggesting that bedrails have the potential to be demeaning to the bed occupant, which may influence clinicians to assume that the occupant has diminished mental or physical capacity26. If this is true, a person who appears neat and tidy in bed, with an assumed loss of agency, might be considered easier to discharge from hospital. Another strategy used to hasten the discharge of a dependent older adult is to discharge them into a micro-environment (living in one room of their own home), with bedrails and an equipment prescription that allows single-handed care. It can be challenging for therapists in an acute inpatient hospital setting to make ethical patient-centred discharge plans. The discharging therapist must consider the discharge destination when finalising their falls and moving and handling risk assessment, and it may be necessary to share the responsibility of risk mitigation strategies across multiple commissioned organisations or voluntary services (opposed to being contained within one ward of one NHS Trust). There may be pressure to discharge patients with incomplete risk mitigation strategies if the patient is not eligible for funding to commission the care required. Under these circumstances, patient flow may be prioritised over and above respect for autonomy, patient centred care, or establishing a rehabilitation environment that carries a higher falls risk. This shift in priority was discussed at the 2024 Royal College of Nursing Congress49, highlighting the ongoing debate between efficient patient management and the ethical considerations of a patient- centred discharge plan. Sturm et al. identified 49 factors, contained within 5 themes, that influence physiotherapists’ ethical decision-making and reported that ‘physiotherapists are regularly confronted with an increasing diversity and complexity of both healthcare environments and ethical challenges.’ The themes are: Individual (relating to the physiotherapist), relational (such as power asymmetry), organizational, situational, and societal. They go on to state that physiotherapists require the ability to prioritise one ethical value over another, and at times, this is more complex than right versus wrong50. A qualitative inquiry into the use of bedrails in a person’s own home would be novel and add significantly to the literature in this area. From a broader perspective, a qualitative inquiry into how community physiotherapists and therapy support workers balance ethics and risk when goal setting and designing therapeutic interventions incorporating the restoration of function and falls prevention would be useful in progressing this area. There is no empirical evidence to support the use of bedrails as a falls prevention device. Additionally, there is a dearth of inquiry into the perspective of the user or into bedrail use in a person’s own home. Clinicians are advised to consider bedrail prescriptions with a sense of responsibility and inquisitive inquiry to support both ethical and lawful prescriptions. Ethical approval and consent were not required. No data are associated with this article Located in OSF repository. Available from: https://osf.io/xepzm/?view_only=4ccf5828cf6949bcb73cedaf36caa985 OSF: Exploring the use of bedrails when used to support adults: A scoping review. 10.17605/OSF.IO/XEPZM This project contains the following extended data: License: CC0 1.0 Universal14. Faculty Opinions recommendedReferences - 1. Medicines and Healthcare products Regulatory Agency: Bed rails: management and safe use. 2020; [updated 2023 Aug 30; cited 2024 Apr 9]. Reference Source - 2. Healey F, National Patient Safety Agency: Bedrails - Reviewing the evidence. A systematic literature review. 2007; [cited 2024 Apr 9]. Reference Source - 3. Shanahan DJ: Bedrails and vulnerable older adults: how should nurses make 'safe and sound' decisions surrounding their use? Int J Older People Nurs. 2012; 7(4): 272–281. PubMed Abstract | Publisher Full Text - 4. Mental capacity Act 2005. Act of Parliament Legislation (England and Wales). [cited 2024 May 12]. Reference Source - 5. 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Publisher Full Text Author details Author details 1 Cornwall Partnership NHS Foundation Trust, Bodmin, England, UK 2 Faculty of Health and Life Sciences, University of Exeter, Exeter, UK 2 Faculty of Health and Life Sciences, University of Exeter, Exeter, UK Vicky Farrell Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Resources, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Resources, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Abigail Hall Roles: Conceptualization, Formal Analysis, Funding Acquisition, Investigation, Methodology, Resources, Software, Supervision, Validation, Visualization, Writing – Review & Editing Roles: Conceptualization, Formal Analysis, Funding Acquisition, Investigation, Methodology, Resources, Software, Supervision, Validation, Visualization, Writing – Review & Editing Victoria Goodwin Roles: Conceptualization, Software, Supervision, Writing – Review & Editing Roles: Conceptualization, Software, Supervision, Writing – Review & Editing Competing interests No competing interests were disclosed. Grant information This project is funded by the National Institute for Health and Care Research (NIHR) under its [‘Research for Patient Benefit (RfPB) Programme’ (Grant Reference Number PB-PG-NIHR305094)]. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Article Versions (3) Copyright © 2025 Farrell V et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. metrics VIEWS $counts.viewCount downloads Citations CITE how to cite this article Farrell V, Hall A and Goodwin V. Exploring the use of bedrails when used to support adults: A scoping review. [version 1; peer review: 1 approved with reservations]. NIHR Open Res 2025, 5:22 (https://doi.org/10.3310/nihropenres.13829.1) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. track receive updates on this article Track an article to receive email alerts on any updates to this article. Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE ApprovedThe paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approvedFundamental flaws in the paper seriously undermine the findings and conclusions Version 1 VERSION 1 PUBLISHED 10 Mar 2025 Views 0 How to cite this report: Okoye SM. Reviewer Report For: Exploring the use of bedrails when used to support adults: A scoping review. [version 1; peer review: 1 approved with reservations]. NIHR Open Res 2025, 5:22 (https://doi.org/10.3310/nihropenres.15024.r35006) The direct URL for this report is: https://openresearch.nihr.ac.uk/articles/5-22/v1#referee-response-35006 https://openresearch.nihr.ac.uk/articles/5-22/v1#referee-response-35006 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Reviewer Report 27 May 2025 Safiyyah M. Okoye, Drexel University, Philadelphia, Pennsylvania, USA Approved with Reservations VIEWS 0 This article is a scoping review of the literature that aims to (a) identify and map the current evidence base on the use of bedrails, and (b) identify gaps that may direct future research areas. Overall the article synthesizes findings ... Continue reading 2. Haddaway NR, Collins AM, Coughlin D, Kirk S: The Role of Google Scholar in Evidence Reviews and Its Applicability to Grey Literature Searching.PLoS One. 2015; 10 (9): e0138237 PubMed Abstract | Publisher Full Text I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close This article is a scoping review of the literature that aims to (a) identify and map the current evidence base on the use of bedrails, and (b) identify gaps that may direct future research areas. Overall the article synthesizes findings on this important topic in a way that is digestible and actionable at the micro, meso, and macro levels. The article would benefit from better organization of the Results section, and a revision of the Discussion section that focuses only on discussing and interpreting key findings from the Results section of the review. Another, more minor comment is that there are several areas where more detail is needed in order to ensure comprehension of the article by readers who are not as closely familiar with the topic, as well as international readers. - Are sufficient details of the methods and analysis provided to allow replication by others? - I suggest the authors mention what specific types of gray literature they expected to find using Google Scholar, as this is a limited source of gray literature. The following citations discuss the use of Google Scholar for grey literature searching: Google Scholar and Scopus. J Med Libr Assoc. 2016 (Ref 1). - Haddaway NR, Collins AM, Coughlin D, Kirk S. (Ref 2) - Please include a citation for Rayyan - The article would benefit from better organization of the Results section. While reading the results section I was not easily able to find all the information I needed to interpret the results and I was also not sure of the themes of the narrative report of the results. - I suggest that the authors include Table 1 in body of the manuscript if possible, same as they have included Figures 1 -3. Table 1 is referred to in the text and also seems to be related to Figure 2, but because it is included as a supplementary file it is difficult to navigate to and use as a complement to the text in the results section. - In Figure 2, what are the 3 columns of boxes representing? It is difficult to interpret this diagram. Does it relate to the information provided in the “Clinical drivers for bedrail use” section of the results? Another question is which of the clinical drivers are choices and actions made by organizations vs made by individual clinicians (as mentioned in para 4 of the “Harm” section). Please revise Figure 2 so it stands alone as a figure. - I suggest that the authors include 1-3 sentences in the beginning of the results section to orient to the reader to the themes that will be presented in the section. These themes should then match the subheadings in a logical manner. See below for an example outline of a revised Results section, along with some notes for further clarification: - Overview - Clinical Drivers of Bedrail Use - Framework to understand clinical drivers (figure 2, table 1) - Differences by geographical context: UK and Ireland vs. US - Prevalence of bedrail use – clarify if this is intended to be a report of prevalence in UK and Ireland only, or across the geographic contexts included in the scoping review results - Impact of Bedrail Use - Balance of ethical imperatives - Harm - Behavior change within organizations – might this go in the “clinical drivers section?” - Experience of the user - Alternatives to bedrails – might this go in the “clinical drivers section?" - There are instances in the Discussion section where a topic is discussed that was not adequately reported in the Results section. In general, the discussion section should focus on a few key findings from the review, along with elaboration and interpretation and integration of these findings into the existing literature and discussion of implications of these findings for clinical practice and future research, etc. One example of this is the reference to “paternalistic device” in paragraph 2 of the discussion, as well as in the abstract. In the current version of the article, there is not adequate definition of this term, there is also not a citation to refer the reader to further information, and further this term is not reported in the Results section as a finding in the literature review. I suggest the authors review their results to see if anything related to bedrails as a “paternalistic device” was found, and if so, then in the Discussion section provide a more thorough discussion of this finding. Also, if the authors decide to elaborate, I suggest they tie in how it relates to their findings that some patients wished to use bedrails (as mentioned in paragraph 2 of the “Experience of the user” section). Alternatively, I suggest removing reference to this term from the article. Another topic introduced in the discussion but not mentioned in the Results section was “evidence regarding bedrail use in a person’s own home” (see paragraph 5 of the Discussion section). I suggest the authors comment on the lack of findings in the results section before mentioning this in the discussion. Further, I suggest the authors thoroughly review the remainder of the discussion to ensure that other topics are first introduced in the Results section before the Discussion section. - Introduction - Para 1, please provide examples of moving and handling products for this sentence “…or when bedrails are recommended by the manufacturers of moving and handling products” - Results - Para 1 under UK and Ireland subheading – authors write “In three of the five snapshot audits…” please provide a definition of what an “audit” is, as this was unfamiliar to this reader. - Para 2, under Prevalence of use subheading – please provide examples of advancements in bed technology for this sentence “The authors also expressed concerns that bedrail use is increasing over time, partly due to advancements in bed technology…” - Para 1 under Behavior change within organizations subheading – This sentence was unclear and should be revised “The authors failed to include details in their methodologies, which demonstrated acknowledgement of or control over the variables” - Are the rationale for, and objectives of, the Systematic Review clearly stated? Yes - Are sufficient details of the methods and analysis provided to allow replication by others? Partly - Is the statistical analysis and its interpretation appropriate? Not applicable - Are the conclusions drawn adequately supported by the results presented in the review? Partly

1. Bonato S: Google Scholar and Scopus. Journal of the Medical Library Association. 2016; 104 (3). Publisher Full Text2. Haddaway NR, Collins AM, Coughlin D, Kirk S: The Role of Google Scholar in Evidence Reviews and Its Applicability to Grey Literature Searching.PLoS One. 2015; 10 (9): e0138237 PubMed Abstract | Publisher Full Text Competing Interests: No competing interests were disclosed. Reviewer Expertise: Gerontology, nursing CITE HOW TO CITE THIS REPORT Okoye SM. Reviewer Report For: Exploring the use of bedrails when used to support adults: A scoping review. [version 1; peer review: 1 approved with reservations]. NIHR Open Res 2025, 5:22 (https://doi.org/10.3310/nihropenres.15024.r35006) The direct URL for this report is: https://openresearch.nihr.ac.uk/articles/5-22/v1#referee-response-35006 https://openresearch.nihr.ac.uk/articles/5-22/v1#referee-response-35006 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. - Author Response 13 Mar 2026Vicky Farrell, Rehabilitation, Cornwall Partnership NHS Foundation Trust, Bodmin, UK13 Mar 2026Author ResponseOutline The results and discussion section have been revised and re-ordered. Terminology that required clarity such as examples of moving and handling products have been expanded. Definition of grey literature has been expanded and a ... Continue reading Outline The results and discussion section have been revised and re-ordered. Terminology that required clarity such as examples of moving and handling products have been expanded. Definition of grey literature has been expanded and a citation for Rayyan has been added.

The results section has been restructured around five themes identified within the literature: 1. Clinical drivers of bedrail use 2. Prevalence of use 3. The impact and reported harm associated with bedrails 4. The experiences of people involved in decisions about bedrails use 5. Balancing competing ethical imperatives when considering whether to prescribe or withhold bedrails. Table 1 Unfortunately, NIHR Open does not permit addition of Table 1 in the main body of the article and requests that it is in a repository. Snapshot audit Prevalence of bedrail use was most frequently captured using snapshot audits, defined as observational reviews of occupied inpatient beds, conducted at a single point in time, in non-specialist areas of care or in care homes. 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 occupied beds using bedrails. Figure 1 and 2. These have been removed. With the revised results and description, they no longer add to the paper.

Comments expanding beyond information identified in the results section have been removed, the term paternalistic has been removed, the discussion should now read much more succinctly and coherently.Outline The results and discussion section have been revised and re-ordered. Terminology that required clarity such as examples of moving and handling products have been expanded. Definition of grey literature has been expanded and a citation for Rayyan has been added.Competing Interests: None Close

The results section has been restructured around five themes identified within the literature: 1. Clinical drivers of bedrail use 2. Prevalence of use 3. The impact and reported harm associated with bedrails 4. The experiences of people involved in decisions about bedrails use 5. Balancing competing ethical imperatives when considering whether to prescribe or withhold bedrails. Table 1 Unfortunately, NIHR Open does not permit addition of Table 1 in the main body of the article and requests that it is in a repository. Snapshot audit Prevalence of bedrail use was most frequently captured using snapshot audits, defined as observational reviews of occupied inpatient beds, conducted at a single point in time, in non-specialist areas of care or in care homes. 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 occupied beds using bedrails. Figure 1 and 2. These have been removed. With the revised results and description, they no longer add to the paper.

Comments expanding beyond information identified in the results section have been removed, the term paternalistic has been removed, the discussion should now read much more succinctly and coherently. COMMENTS ON THIS REPORT - Author Response 13 Mar 2026Vicky Farrell, Rehabilitation, Cornwall Partnership NHS Foundation Trust, Bodmin, UK13 Mar 2026Author ResponseOutline The results and discussion section have been revised and re-ordered. Terminology that required clarity such as examples of moving and handling products have been expanded. Definition of grey literature has been expanded and a ... Continue reading Outline The results and discussion section have been revised and re-ordered. Terminology that required clarity such as examples of moving and handling products have been expanded. Definition of grey literature has been expanded and a citation for Rayyan has been added.

The results section has been restructured around five themes identified within the literature: 1. Clinical drivers of bedrail use 2. Prevalence of use 3. The impact and reported harm associated with bedrails 4. The experiences of people involved in decisions about bedrails use 5. Balancing competing ethical imperatives when considering whether to prescribe or withhold bedrails. Table 1 Unfortunately, NIHR Open does not permit addition of Table 1 in the main body of the article and requests that it is in a repository. Snapshot audit Prevalence of bedrail use was most frequently captured using snapshot audits, defined as observational reviews of occupied inpatient beds, conducted at a single point in time, in non-specialist areas of care or in care homes. 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 occupied beds using bedrails. Figure 1 and 2. These have been removed. With the revised results and description, they no longer add to the paper.

Comments expanding beyond information identified in the results section have been removed, the term paternalistic has been removed, the discussion should now read much more succinctly and coherently.Outline The results and discussion section have been revised and re-ordered. Terminology that required clarity such as examples of moving and handling products have been expanded. Definition of grey literature has been expanded and a citation for Rayyan has been added.Competing Interests: None Close

The results section has been restructured around five themes identified within the literature: 1. Clinical drivers of bedrail use 2. Prevalence of use 3. The impact and reported harm associated with bedrails 4. The experiences of people involved in decisions about bedrails use 5. Balancing competing ethical imperatives when considering whether to prescribe or withhold bedrails. Table 1 Unfortunately, NIHR Open does not permit addition of Table 1 in the main body of the article and requests that it is in a repository. Snapshot audit Prevalence of bedrail use was most frequently captured using snapshot audits, defined as observational reviews of occupied inpatient beds, conducted at a single point in time, in non-specialist areas of care or in care homes. 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 occupied beds using bedrails. Figure 1 and 2. These have been removed. With the revised results and description, they no longer add to the paper.

Comments expanding beyond information identified in the results section have been removed, the term paternalistic has been removed, the discussion should now read much more succinctly and coherently. Alongside their report, reviewers assign a status to the article: - Approved - Approved with reservations - Not approved | Invited Reviewers | || |---|---|---| | 1 | 2 | | | Version 3 (revision) 16 Apr 26 | read | | | Version 2 (revision) 13 Mar 26 | read | | | Version 1 10 Mar 25 | read | Sign up for content alerts You are now signed up to receive this alert Alongside their report, reviewers assign a status to the article: Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions Provide sufficient details of any financial or non-financial competing interests to enable users to assess whether your comments might lead a reasonable person to question your impartiality. Consider the following examples, but note that this is not an exhaustive list: Examples of 'Non-Financial Competing Interests' - Within the past 4 years, you have held joint grants, published or collaborated with any of the authors of the selected paper. - You have a close personal relationship (e.g. parent, spouse, sibling, or domestic partner) with any of the authors. - You are a close professional associate of any of the authors (e.g. scientific mentor, recent student). - You work at the same institute as any of the authors. - You hope/expect to benefit (e.g. favour or employment) as a result of your submission. - You are an Editor for the journal in which the article is published. Examples of 'Financial Competing Interests' - You expect to receive, or in the past 4 years have received, any of the following from any commercial organisation that may gain financially from your submission: a salary, fees, funding, reimbursements. - You expect to receive, or in the past 4 years have received, shared grant support or other funding with any of the authors. - You hold, or are currently applying for, any patents or significant stocks/shares relating to the subject matter of the paper you are commenting on. Sign up for content alerts and receive a weekly or monthly email with all newly published articles Register with NIHR Open Research Already registered? Sign in close Error If you are a previous or current NIHR award holder, sign up for information about developments, publishing and publications from NIHR Open Research. We'll keep you updated on any major new updates to NIHR Open Research Sign In If you've forgotten your password, please enter your email address below and we'll send you instructions on how to reset your password. Email us for further assistance. The email address should be the one you originally registered with F1000. Email address not valid, please try again You registered with F1000 via Google, so we cannot reset your password. To sign in, please click here. If you still need help with your Google account password, please click here. You registered with F1000 via Facebook, so we cannot reset your password. To sign in, please click here. If you still need help with your Facebook account password, please click here. Code not correct, please try again Server error, please try again. If your email address is registered with us, we will email you instructions to reset your password. If you think you should have received this email but it has not arrived, please check your spam filters and/or contact for further assistance. Please wait...