Nurses are challenged to keep patients safe from the risk of falling and sustaining an injury. The literature supports efforts by health care agencies and providers to reduce the incidence of falls. However, despite all the regulatory requirements, processes, and tools that nursing staff have available, falls occur daily (Skaggs, Mion, & Shoor, 2014; Tzeng, 2011). While fall risk assessment tools are beneficial, specific interventions that are individualized to the patient’s risk may decrease the incidence of injurious falls (Barker, 2014). Little has been published to capture how both patient and nursing knowledge and perception of barriers together may affect patient falls. A mixed methods research study that examined the perception and knowledge of patients and care providers about barriers to preventing injurious falls supports recommendations that may decrease a patient’s risk for injurious falls.
Purpose
This mixed method research study utilized a convenience sample of registered nurses (RNs), nursing assistants (NAs), and patients from four hospitals in rural and urban settings in the Midwest. The study was approved by the health care system’s Institutional Review Board. The purpose of this research study was three-fold. First was to identify what patient factors influence nurses’ decisions about hospitalized patient fall risks, including risk for an injury related to falling, and instituting fall risk strategies. The second purpose was to identify factors that influence the patient’s perspective of their own risk for experiencing a fall or injurious fall. Third, the study identifies barriers recognized by the nurses, nursing assistants and patients to prevent a fall.
Methods
The methods used in the research study were: a) a factorial survey with vignettes, b) RN and care provider focus groups, and c) one-on-one patient interviews. The factorial survey with vignettes was developed by the researchers and employed randomly created vignettes with six patient variables: age, medical condition, mobility, cognition, fall history, and medications, Three questions requiring a response on a Likert scale followed each vignette and were used to determine significance of one or more patient variables in influencing the registered nurse’s decision to identify the patient at risk for a fall, whether the fall will result in an injury, and the decision to institute fall precautions. 465 surveys were distributed to nurses; 93 surveys were returned with 558 vignettes completed. 500 vignettes were required for significance. The researchers created a questionnaire about perceptions of patient fall experiences for five focus groups that totaled 20 RNs and four NAs. The Older Adults’ Perceptions of Fall Perceptiontool (Miller, 2010) was utilized for 75 one- on – one patient interviews. Patients were interviewed if they were over the age of 65, spoke English, were alert and oriented, and pain free.
Results
Survey Vignettes
The factorial survey method used multiple regression procedures to determine the significance of the six patient variables in the vignettes. Patient age, fall history, and cognition were significant for the nurses’ perceived risk of the patient falling. Age, fall history, medical problem, and cognition were significant for the nurses’ perceived risk of the patient to experience a fall related injury. Age, fall history and medications were significant to the likelihood of the nurse to implement a fall risk strategy.
Focus Groups
Constant comparative analysis between focus groups was used to identify common phrases which were collapsed into four areas of concern that were voiced by the RNs and NAs. The first area of concern was that environment issues contribute to falls. Room environment, change of environment, arrangement of environment, and location of patients’ rooms on the nursing unit were discussed as contributors to fall risk. The second area communication/education is needed to prevent falls reflected the focus groups’ conversation about lack of follow through with established interventions by both health care providers and patients, and lack of communication between health care providers. The third area was that a change in patient condition requires action. RNs discussed that the addition of and changes in medications, and changes in patient’s mental and physical condition warrant additional assessment and intervention. Futhermore, the use of judgement above the presence of existing data is necessary. The fourth area of concern was that lack of staffing and staffing patterns contribute to falls; RNS and NAs identified the need for more patient sitters and staff.
One-on-one Patient Interviews
Patients were asked about their fall history, knowledge of falls, fall risk, and precautionary actions during a 30-minute audio taped interview. Interviews were coded and categorized into themes with the goal of repetitive expressions of meaning to ensure saturation. Three themes that were supported by common statements from the patients were: a) knowledge of the potential for falls through education, b) lifestyle alterations with advancing age, and c) fall risk denial/ambivalence despite education. Patients reported education about falls via TV commercials, advice from family members and friends, but not from health care providers. Several patients denied being told about hospital fall risk even though they wore a risk bracelet or had a sign in their hospital room. Patients had ideas about decreasing fall risk in their home environment because of their age. Of the 75 patients, 56 reported a history of falls; 27 of 56 reported falling more than one time, and 25 of the 56 reported injuries associated with a fall.
Discussion and Recommendations
Fall history was noted as a factor by nurses in all three areas of the survey vignettes including the decision to institute fall risk interventions; one- third of the patients interviewed reported injury related falls – mostly at home. The patients who were interviewed did not associate their knowledge of injurious falls with their own fall risk in the hospital. Patients may not think that they are at risk for falling which may contribute to poor compliance with fall risk interventions (Haines & McPhail, 2011).
Nurses in the focus groups cited lack of communication between health care providers and lack of understanding by the patient as barriers to prevent injurious falls. Nurses also indicated that staffing and staffing patterns influence fall rates. A factor associated with decreased falls in adult hospitalized patients include higher staffing ratios (Cox, Thomas-Hawkins, Pajarillo, DeGennaro, Cadmus, Martinez, 2015).
Nurses suggested that reassessment for changes in patient status, education using words that patients understand, and using judgement beyond knowledge of existing data may prevent injurious falls. However, in the survey vignettes, cognition was significant in nurses’ perceptions of falls and injuries related to falls, but patient cognition was not a factor in nurses’ likelihood to implement fall risk interventions. Wilson, Montie, Conlon, Reynolds, Ripley, and Titler (2016) recommend that fall risk interventions be personalized to patient’s individual fall risks.
Recommendations
The collaborative partnership for this study included researchers from academia and nursing leaders in the practice setting and met a need for recommendations for a mid-west the health care system experiencing an increase in fall rates. Three recommendations are presented. Recommendation 1- Evaluate use of the current fall risk assessment tool and add a critical thinking component to individualize care as well as a component to identify the level of risk for injury. Consider more frequent fall risk assessments with the tool and note that a change in patient status or environment should trigger additional assessments. Add practice alerts to the electronic health record for additional fall risk assessments.
Recommendation 2- Reframe patient education. Change the verbiage of patient education and individualize to patient needs. Engage the patient and family in the fall risk plan and be clear about what a fall risk indicates- let the patient know that signs, bracelets and interventions are indicators that the patient is at risk for a fall. Encourage teach back of concepts presented to patient.
Recommendation 3- Reinforce the education of nurses and include concepts listed in recommendations #1 and #2. Provide patient scenarios that indicate a change in fall risk level, and that a change in fall risk level indicates a need for additional or different interventions.
In conclusion,understanding patients' and care providers’ knowledge and perceptions of barriers to prevent falls provides an opportunity to develop a comprehensive plan which may prevent or remove barriers related to falls and fall risks, decrease injuries related to falls, and therefore may impact patient outcomes and decrease healthcare costs long term.