Assignment1
Title Page Abstract: What should the reader expect to find in your paper? This should be a brief paragraph of approximately 3-5 sentences. Body: The body of the research critique should be 2100-2800 words (approx. 6-8 pages). Reference Page: This should include the article being critiqued and any sources you used to support your analysis of the article. This article should be cited in the text in the introduction of your paper. Use the textbook as a reference to support your ideas or decision regarding the appropriateness of the methodology used in the article, should cite Fain in the text of the paper and then include as a complete reference on the reference page. Using on this research article listed please answer the question below. Article: Inpatient fall prevention from the patient’s perspective: A qualitative study: Link Attached Textbook: READING, UNDERSTANDING, AND APPLYING Nursing Research Fifth Edition James A. Fain, PhD, RN, BC-ADM, FAA: Link Attached. PLEASE KEEP THE HEADING FOR EACH AREA NOTED I. The Researcher a. Who is the researcher? b. What qualifies him/her to undertake the study? c. Who sponsored the research and/or provided sources of funding? II. The Title a. Is the title of reasonable length? Clear? Concise? b. Are the important study variables mentioned in the title? If so, what are they? c. Does the title suggest the population under investigation? If so, who? III. The Problem Statement a. Was the problem statement clearly stated? b. In your judgement, is the study significant to nursing practice? State your rationale. c. What are the research variables and are research variables explained? d. Does the problem meet the criterion of research ability? If so, state how. If not, why not? IV. Protection of Human Rights a. Were the rights of subjects observed? Did the researcher address any ethical concerns? b. Did the researcher(s) clearly state that one of more Institutional Review Boards approved the study? What organization(s) were the IRB’s affiliated with? c. If not stated that the research received approval from an IRB, what are your thoughts regarding the absence of approval? d. What suggestions would you make to strengthen the protection of the subjects? V. Purpose of the study a. What did the researcher intend to study? b. Is the purpose statement clearly stated or described? Provide rationale for your statement. VI. Review of the Literature a. Are the articles relevant to the problem? b. Are the researcher’s literature sources: 1. primary? 2. secondary? 3. current? c. Is the review merely a summary of past work or does it critically appraise and compare the contributions of key studies? 1. Does it identify weaknesses? 2. Does it identify important gaps in literature? d. Is it logically organized so that it builds a case for conducting a new study? I. Theoretical/Conceptual Framework: a. Was a theoretical framework clearly described? If yes, describe. b. If no, does the researcher explain why a framework was not used? c. If no, does the absence detract from the significance of the research? II. Hypotheses/Research Questions a. Are hypotheses clearly stated? If yes, describe. If no, explain why there might not be a hypotheses. b. What is the research question(s)? c. Is the research question(s) clearly stated in the article? III. Research Approach/Design a. State the research design. Is the method clearly stated in the article? b. What are the research design’s strengths and weaknesses? c. Are the variables clearly defined? Describe. d. How does the design control for threats to: 1. Internal validity. 2. External validity. IV. Sampling and Sample a. How was the number of subjects for the study determined? b. What were the criteria for sample selection? c. What was the sampling design used? d. Was this a probability or nonprobability method of selection? e. Was the sample size appropriate? Was the sample representative? f. How many subjects were lost during the course of the research study? Were the reasons for loss (attrition) of subjects explained? Did the researcher(s) explain how this loss affected the study outcomes? g. To what population can the findings be generalized? h. What suggestion would you make to strengthen the sample selection? I. Data Collection Methods a. What procedures were used to collect data? Were the procedures clearly identified and described by the researcher(s)? If no, explain. b. Are the instruments/scales used to collect the data appropriate for the problem or method? c. Are these instruments and scales reliable? Valid? 1. Type of reliability? How was it established? 2. Type of validity? How was it established? d. Did the researcher(s) clearly explain if the tools had been tested for validity and reliability? e. Are the scoring procedures explained? Answer for each instrument used. II. Data Analysis a. Did the researcher clearly explain how the data analysis was performed? Explain. b. Are the data analysis procedures appropriate to the data collected? c. If Quantitative: What statistical measures were used to analyze the data? d. If Quantitative: What types of tables were presented? Were the tables clearly labeled? What data was included in the tables? e. If Qualitative: What qualitative data analysis method was used to analyze the data? Did the researcher explain this process? III. Results a. Did the researcher clearly describe the results (outcomes) of the study? b. Did the study deviate from the original plan? Were all hypotheses and questions analyzed? Describe. c. Quantitative: Did the researcher(s) clearly describe statistical analysis? d. Does the researcher address the results in relationship to all research questions and/or hypotheses stated in the article? If yes, explain. If no, describe what was not addressed. IV. Discussion a. Does the researcher(s) clearly discuss the limitations, the outcomes, and threats to internal and external validity of the study results? b. Does the researcher relate the findings to the problem or purpose of the study? c. Does the researcher state whether study results support or refute previous studies? d. Are there any unexpected findings? V. Implications and Recommendations a. Has the researcher identified implications beyond the purpose originally identified in the study? Are they warranted? Give your rationale. b. Has the researcher(s) indicated the implications of the findings for nursing practice, education and/or research? c. What were the researcher’s recommendations? d. Are the recommendations thorough, consistent with the findings, and consistent with related research results? e. Are recommendations made concerning how the study’s methods might be improved? f. What recommendations are made for future research investigations? g. Is the information provided in this study sufficiently clear and complete so that the study may be replicated? h. Do you agree with the conclusions and recommendations? Based on your critique, do you believe this is a valid study that can be used to change practice or health care in general? Explain
Contents lists available at ScienceDirect
Applied Nursing Research
journal homepage: www.elsevier.com/locate/apnr
Original article
Inpatient fall prevention from the patient’s perspective: A qualitative study
Bethany Radecki, MSN, RN, ACNS-BCa,⁎,
Staci Reynolds, PhD, RN, ACNS-BC, CCRN, CNRN, SCRNb, Areeba Kara, MD, MS, FACPa
a Indiana University Health Methodist Hospital, 1701 North Senate Blvd, Indianapolis, IN 46202, USA
b Duke University Hospital, 2301 Erwin Road, Durham, NC 27710, USA
A R
T
I C L E I N F O
Keywords:
Perception
Nurse-patient relationship
Falls
Fall prevention
Patient centered
A B S T R A C T
Aim: The aim of this study was to describe the patient’s perspective of fall prevention in an acute care setting to
aid in the design of patient centered strategies.
Background: Falls are one of the most common adverse events in hospitals and can lead to preventable patient
harm, increased length of stay, and increased healthcare costs. There is a need to understand fall risk and
prevention from the patients’ perspectives; however, research in this area is limited.
Methods: To understand the patient perspective, semi-structured interviews were conducted with twelve patients
at an academic healthcare center.
Results: Qualitative analysis revealed three major themes: (1) how I see myself, (2) how I see the interventions;
and (3) how I see us. The theme “How I see myself” describes patients’ beliefs of their own fall risk and includes
the sub-themes of awareness, acceptance/rejection, implications, emotions, and personal plan. Interventions,
such as fall alarms, are illustrated in the theme “How I see the interventions” and includes the subthemes what I
see and hear and usefulness of equipment. Finally, “How I see us” describes barriers to participating in the fall
prevention plan.
Conclusions: Most fall prevention programs favor clinician-led plan development and implementation. Patient
fall assessments needs to shift from being clinician-centric to patient-centric. Nurses must develop relationships
with patients to facilitate understanding of their needs. Developing these truly patient-centered programs may
reduce the over-reliance on bed alarms and allow for implementation of strategies aimed to mitigate modifiable
risk factors leading to falls.
1. Introduction
Falls and falls with injury are one of the most commonly reported
adverse events in hospitals. In the United States, approximately
700,000 to 1,000,000 patients fall annually during their hospitalization
and up to half of these falls result in an injury (Agency for Healthcare
Research and Quality [AHRQ], 2013). Falls may prolong length of stay
and contribute to morbidity, making fall prevention a priority for
hospitals (Miake-Lye, Hempel, Ganz, & Shekelle, 2013).
Fall prevention is complex, with single interventions lacking effi-
cacy compared to multimodal approaches (Cameron et al., 2012).
Evidence based practice operates where clinical judgment, scientific
evidence and patients’ values and preferences converge (Melnyk &
Fineout-Overholt, 2015). Effective fall prevention therefore requires a
partnership between the patient and staff that respects and includes the
patient’s view. Therefore, the need to study and describe the patient’s
perspective exists in tandem with the need to investigate processes and
interventions aimed to decrease falls.
While previous studies have explored patients’ perspectives of fall
prevention programs in a community setting, less evidence describes
this subject in the acute care setting (Chen et al., 2016; McMahon,
Talley, & Wyman, 2011; Pohl et al., 2015). Shuman et al., (2016) in-
terviewed fifteen hospitalized patients to understand their perceptions
of fall risk and fall prevention interventions. They found that “com-
munication and level of engagement influenced patient perceptions”
suggesting healthcare providers need to include the patient in fall
prevention (Shuman et al., 2016, p. 84). However, this study did not
explore patients’ perceptions of specific interventions or equipment that
is often included in fall prevention programs. Additionally, the study
did not explore patient barriers to participation in fall prevention
strategies while in the hospital.
Patients want to be active participants in their fall prevention plan
(Carroll, Dykes, & Hurley, 2010). Furthermore, patients value the
ability to tailor the approach to meet their individualized needs (Haines
https://doi.org/10.1016/j.apnr.2018.08.001
Received 3 April 2018; Received in revised form 27 July 2018; Accepted 5 August 2018
⁎ Corresponding author.
E-mail addresses: bradecki@iuhealth.org (B. Radecki), Staci.reynolds@duke.edu (S. Reynolds), akara@iuhealth.org (A. Kara).
Applied Nursing Research 43 (2018) 114–
119
0897-1897/ © 2018 Elsevier Inc. All rights reserved.
T
& McPhail, 2011). When patient preference is ignored, patients may
feel their autonomy is threatened (Haines & McPhail, 2011). Weingart
et al., (2011) surveyed patients discharged from the hospital to describe
the association between patient participation in care and the quality
and safety of care. The study identified an inverse relationship between
participation and adverse events (Weingart et al., 2011). Including
patients in their care may therefore decrease the risk of adverse events,
such as falls.
The aim of this study was to describe the patient’s perspective of fall
prevention in an acute care setting to aid in the design of patient-cen-
tered strategies.
2. Methods
A qualitative study was designed to describe the patient’s perspec-
tive of their own fall risk and of the fall prevention interventions im-
plemented by nursing staff. The study was reviewed and approved by
the local Institutional Review Board (protocol #1407636143).
2.1. Setting
The study was conducted in a large, urban, tertiary care, academic
health center in the Midwest. The facility has been designated as a
Magnet Hospital for excellence in nursing services and high-quality
clinical outcomes for patients. Participants were selected from non-in-
tensive care inpatient units. The facility screens all inpatients for fall
risk on admission and every shift. In addition to universal fall risk
prevention measures, additional interventions are matched to patient
specific etiology to mitigate fall risk. Interviews took place over a
period of seven weeks starting October 2014. Data collection was in-
terrupted for a period of five months due to personal leave and was
completed in March 2016.
2.2. Participants
Inclusion criteria for participation included patients who met the
following criteria: a Glasgow Coma Scale of 15, free of cognitive defi-
cits, English speakers, a Johns Hopkins Fall Risk Assessment Tool
(JHFRAT) score of ≥6, admitted to a non-intensive care unit (ICU), a
unit length of stay > 24 h, in a private room for confidentiality, and be
≥18 years of age. Patients that fell during the current hospitalization
were excluded. The JHFRAT screens for known fall risk factors in-
cluding age, fall history, elimination, medication usage, patient care
equipment that tethers, cognition, and mobility status (Poe, Cvach,
Dawson, Straus, & Hill, 2007). The tool calculates a total score that
corresponds to a fall risk level: 0–5 is considered low risk, 6–13 is
moderate risk, and > 13 is considered high risk for falling (Poe et al.,
2007).
The lead investigator (BR), a Clinical Nurse Specialist (CNS), was
responsible for data collection. On selected days, the investigator asked
the unit charge nurse for a list of patients with JHFRAT scores ≥6
(patients considered at least at moderate risk of falling). Guided by this
list, the investigator reviewed each patient’s chart to screen for exclu-
sion criteria, as well as to independently verify the fall risk score. For
the units that had more than one patient eligible on a given day, all
names were written on a piece of paper and then drawn out of a cup to
decrease bias.
2.3. Data collection
Each participant was provided a study information sheet describing
the study and measures to ensure confidentiality. Verbal consent was
received to take part in the interview and participants were assigned a
unique participant code. All interviews were conducted by the lead
investigator. A sign was placed on the patient’s door requesting that no
healthcare workers enter the room during the interview. Interviews
were audiotaped and conducted in the patient’s private room using a
standardized open-ended interview approach (Turner, 2010). The in-
terview guide was developed by the investigators with input from local
and national experts in fall prevention. The guide was designed to elicit
patient awareness/perceptions of fall risk and prevention interventions.
Interviews were transcribed verbatim and checked for accuracy. The
interview guide is shown in Table 1.
2.4. Data analysis
After five interviews were completed, the lead investigator reviewed
transcripts to identify themes. Thereafter, data was reviewed after
every two interviews until data saturation was reached. After ten in-
terviews, no new themes emerged. To verify saturation, two more in-
terviews were conducted. As no new themes emerged, data collection
was stopped.
Transcript analysis was guided by constant comparative methods
(Kolb, 2012). During open coding, the team, which consisted of a CNS
and a physician, read all transcripts repeatedly to gain a general un-
derstanding of the data. The team individually analyzed the transcripts
for emerging themes. Together, the team iteratively refined the themes
to reflect meanings in the data. During focused coding, the team in-
dividually organized initial themes into major themes. The team then
met to compare and discuss until consensus was reached. Throughout
the analysis process, investigators practiced reflexivity and examined
negative cases that might lend to alternative explanations of the data.
3. Findings
3.1. Demographics
A total of twelve patients participated in the study, including 7 men
and 5 women. Ages ranged from 38 to 89 years, with a mean of
65.2 years. At the time of the interview, three patients were hospita-
lized in medical progressive care units, three were on medical units and
six were on surgical units. Prior to hospitalization, 11 patients were
living independently without assistance while one was living with a
caregiver and required assistance. Admitting diagnoses included
pneumonia, atrial fibrillation, chronic obstructive pulmonary disease,
falls, and urological surgery. The average JHFRAT fall risk score was 9
with a range of 6–14. Table 2 provides patient characteristics including
fall risk factors. Of the 12 patients, three were considered an automatic
high fall risk because of a history of more than one fall within the six
months before admission. The average length of stay was 5 days (range
1–11 days).
Interviews took an average of six and a half minutes with a range of
2.8 min to 16.8 min. Family members were present during one inter-
view.
Qualitative analysis revealed three major themes that were con-
solidated as follows from the patient’s viewpoint: (1) How I see myself,
(2) How I see the interventions, and (3) How I see us.
Table 1
Patient interview guide.
1. Are you aware that you have been identified as a “fall risk” by the nursing staff?
2. What does that mean to you to be identified as a “fall risk”?
3. When the nurse explained you were a fall risk, did it make sense to you?
4. How do you feel about being identified as a “fall risk”?
5. Do you believe you are a fall risk? Why or why not?
6. What do you believe the nurses are doing to help prevent you from falling?
7. What do you do to prevent you from falling while here in the hospital?
8. Do you feel like you and your nurse share the same fall prevention plan?
9. What are your thoughts and feelings on the usefulness of the interventions we use
to keep you from falling?
10. What keeps you from following the fall prevention plan?
B. Radecki et al. Applied Nursing Research 43 (2018) 114–119
115
4. “How I see myself”
The theme “How I see myself” describes patients’ perspectives of
how they see their personal fall risk. The theme is supported by five
sub-themes including: awareness, acceptance/rejection, implications,
emotions, and personal plan.
4.1. Awareness
Most patients were aware of being identified as a fall risk. A few
patients mentioned supporting evidence of the fact.
“Yea, I got the little band saying so.”
(participant 10)
“They have told me.”
(participant 8)
4.2. Acceptance/rejection
More than half the patients believed they were a fall risk. All that
believed they were at risk had physical limitations that put them at risk.
“Suspect is a better word. What makes me suspect? … We char-
acterize what we visually see. You [nurse] may see a slight limp and
think he may be vulnerable to fall.”
(participant 5)
“It’s because of these horrible headaches … makes me dizzy.”
(participant 11)
Some rejected the notion of being a fall risk when the risks were not
evident or did not impact their mobility. For example, a patient on
anticoagulation who was at risk for injury from a fall stated:
“I don’t understand that [I am a fall risk] because I haven’t fallen.”
(participant 6)
Another patient who was experiencing headaches stated:
“It doesn’t really bother me, because again, I know how steady I really
am.”
(participant 11)
4.3. Implications
Many patients described how the fall risk identification affected
them. While some patients viewed it as a consequence, others con-
sidered it an advantage.
“It means I am in trouble. That you, you know I fall real easy.”
(participant 1)
“I’ve had to spend a lot of time in bed here. Can’t move; can’t do nothing.”
(participant 4)
“Protect me, make me feel safe.”
(participant 7)
4.4. Emotions
Here patients described how being a fall risk made them feel.
“Insecure maybe, unsure of yourself.”
(participant 5)
“Vulnerable”
(participant 9)
“I’ve always done things on my own; even if I was hurt I would do it by
myself. It’s kinda weird to me.”
(participant 8)
4.5. Personal plan
When asked what part the patient played in preventing a fall, they
described the actions they would take such as being careful or holding
on to something.
“Well, I just try to be careful.”
(participant 1)
“Stay close and get a hold of something. That’s the main thing.”
(participant 12)
“I try not to fall. If I have to hold something, I hold on to something. …If I
feel like I’m gonna fall, then I won’t move.”
(participant 7)
Patients also described their role in preventing a fall as something they
did out of an obligation to the nurse.
“I don’t want to let them [nurses] down. If they told me to stay in bed or
stay in the chair, then I wouldn’t cheat on them and do it.”
(participant 2)
“I go by the rules.”
(participant 5)
5. “How I see the interventions”
The second major theme “How I see the interventions” describes
how patients see the fall interventions put into place by the nurses and
is supported by two sub-themes: what I see and hear and usefulness of
Table 2
Characteristics of participants.
Participant Age (years) Gendera Unit type JHFRAT fall scoreb Fall risk factors
1 86 F Surgical 14 Age, fall history, one high risk medication, one tether, mobility
2 89 F Surgical Automatic History of more than one fall within last 6 months
3 59 F Medical progressive 10 Two high risk medications, three tethers, mobility
4 54 M Surgical 8 Two high risk medications, one tether, mobility
5 71 M Medical progressive 10 Age, one high risk medication, three tethers, mobility
6 60 M Surgical 6 Age, two high risk medications
7 62 F Medical Automatic History of more than one fall within last 6 months
8 38 M Surgical 6 Two high risk medications, one tether
9 71 M Medical Automatic History of more than one fall within last 6 months
10 58 M Surgical 9 Two high risk medications, two tethers, mobility
11 66 F Medical 9 Age, elimination, one high risk medication, one tether, mobility
12 68 M Medical progressive 9 Age, two high risk medications, one tether, mobility
a M: Male, F: Female.
b JHFRAT Fall Score 0–5: Low risk, 6–13: Moderate risk, > 13: High risk, automatic: History of > 1 fall within the 6 months before admission.
B. Radecki et al. Applied Nursing Research 43 (2018) 114–119
116
equipment.
5.1. What I see and hear
In describing what nurses did to prevent falls, patients often re-
ported what they saw nurses do and tell them.
“Well, they [nurses] got my bed alarm, chair alarm. Whenever I move or
stand up, they’re in here.”
(participant 6)
“Oh my gosh, they [nurses] don’t let go of you for five seconds. They put
a strap around you and … I’ve been using my walker.”
(participant 2)
“[Nurses] Tell me don’t get up out of the chair or bed unless I hit the call
light.”
(participant 10)
“[Nurses] Checking in on me, making sure I’m sitting down.”
(participant 3)
5.2. Usefulness of equipment
Many found the interventions, such as the bed alarm and gait belt,
useful for the nursing team.
“(The bed alarm) is a good precaution. It makes them [nurses] aware.”
(participant 5)
“I would think they [bed alarms] would be useful if someone accidently
fell out of bed, you know, they could lay there for hours until somebody
knew.”
(participant 10)
“(Gait belt) I would say very [useful] because if they [nurses] were just
holding on to my gown or something I could just slip right down out of
that.”
(participant 10)
However, some patients did not find the interventions useful. One pa-
tient described how the gait belt would not keep him from falling in
relation to his size.
“(Gait belt is) A waste, a waste of time… She [nurse] couldn’t lift me up
if I did fall.”
(participant 12)
Others described how the audible alarms did not deter intentions to get
up unassisted and how the alarms restricted their mobility.
“The bed alarm at night…it was alright. I could have already gotten up if
I wanted to. The chair alarm, the same thing, it would go off, but I would
still gotten up if I wanted to”
(participant 8)
“[Alarms] keep me locked in my bed.”
(participant 4)
One patient described an alternative use for the alarm.
“You [patient] can just lift your hind end up off the cushion and set that
alarm off and that will get you the quickest response of anything.”
(participant 10)
6. “How I see us”
The last major theme “How I see us” describes how the patients
perceived the teamwork between themselves and the nurses to prevent
falls.
Ninety percent of the patients believed they shared the same fall
prevention plan as the nurse. When the patients felt like the
interventions in place were useful, they did not describe any barriers to
participating in the fall prevention plan. The most frequently men-
tioned occurrence negatively influencing the partnership between nurse
and patient was time spent waiting. Patients described how they knew
they were to call the nurse for help when getting out of bed, but their
need to use the bathroom overrode the instructions from the nurse.
“I think they’re [interventions] kinda bad because I would have to sit
there and wait for them to come in, wait for them to sit at the door, it
would be like 10-15 minutes and I have to go to the bathroom. But you’ll
see, if I have to go to the bathroom, I have to go to the bathroom.“
(participant 4)
“Yesterday, I had to wait a long time. I had to wait to go pee and when
you take that Lasix, it don’t work.”
(participant 12)
“(Waiting) you think you’re going to lose it because you have to go pee,
and you call for someone and they don’t come.”
(participant 11)
7. Discussion
To be truly patient-centered, it is important to both understand
patient perspectives and develop strategies in partnership with them.
Our interviews with patients about fall risk and fall prevention plans
provide insights that may be used to inform the design of more effective
fall prevention strategies.
Previous investigations focusing on patients’ perceptions of their
own fall risk have found that patients do not perceive their risk accu-
rately (Shuman et al., 2016; Sonnad, Mascioli, Cunningham, &
Goldsack, 2014). Twibell, Siela, Sproat, and Coers (2015) found more
than half of the patients who were considered at risk of falling as as-
sessed by nursing did not believe that they were likely to fall. Contra-
dictory to this, in our sample, most patients were aware that they were
identified as a fall risk. This heightened awareness may be attributed to
the initiatives implemented by the facility during the study period
which included discussing fall risk factors with patients. However, si-
milar to other researchers, while several patients were both aware and
accepting of their fall risk, this acceptance seemed to be limited to
patients with physical limitations that impacted their mobility. Patients
without physical limitations did not believe they were at risk and often
reasserted their steadiness during the interview as protection against
falls. Previous researchers also found patients’ acceptance of risk was
low because they could walk easily (Sonnad et al., 2014). These find-
ings suggest that patients’ beliefs of fall risk may be linked to their
perception of their ability to mobilize.
While the fall assessment tool is nurse-centric and identifies factors
for modification by the medical team, factors that contribute to risk
such as laboratory values, medication changes, or post-ICU weakness
may not be tangible or ‘real’ for the patient. Despite nurses telling pa-
tients why they are at risk for a fall, patients may not accept these
reasons if they do not limit their mobility. This mismatch between
factors that place patients at risk that are routinely assessed in fall risk
scores and patients’ acceptance of these risks is likely a barrier to ef-
fective partnerships between patients and the care team. There may be
a role for more collaborative risk assessments that emphasize patient
self-assessment and practical demonstrations of their current strength
and gait stability.
Despite a lack of evidence supporting the effectiveness of bed and
chair alarms to prevent falls, they are often used in fall prevention
programs (Hempel et al., 2013; Sahota et al., 2014). Our patients
identified the alarms as part of the fall prevention plan, but most
viewed the alarm as a useful alert for nurses when a patient was out of
bed rather than a reminder to wait for help. Of note, only one patient
described the alarm as a useful tool to remind themselves to stay in bed
or to call for help. The discordance in how nurses and patients view
B. Radecki et al. Applied Nursing Research 43 (2018) 114–119
117
alarms may foster confusion and a false sense of security in both pa-
tients and nurses, creating scenarios in which patients may get out of
bed and fall before staff members respond. An emerging behavior of
using the alarm as a call light to ensure a rapid response was shared by
one patient. If this finding is replicated in other investigations, then
such “false alarms” may contribute to alarm fatigue. Alarm fatigue
creates unsafe environments where staff may omit or delay responses to
actual fall situations.
Another patient described how the alarms confined them to bed.
The focus on fall prevention may be inadvertently contributing to the
immobilization of hospitalized patients (Growdon, Shorr, & Inouye,
2017). Researchers looking at levels of mobility experienced by older
hospitalized veterans found patients spent most of the time lying in bed
(Brown, Redden, Flood, & Allman, 2009). The reliance on bed and chair
alarms to prevent falls has created unintended consequences for clin-
icians and patients. Future research is needed to reevaluate the use of
alarms in fall prevention programs.
We found that the biggest barrier to following the fall prevention
plan for patients was waiting on assistance for toileting. Even when
patients perceive they are at risk for falling, they may not follow
through on the plan to reduce this risk. These findings are consistent
with other studies where participants found waiting for a response to
their needs as a deterrent to fall prevention (Carroll et al., 2010; Hill
et al., 2016). Twibell et al. (2015) found that even if patients intended
to follow the fall prevention plan, if help was not available quickly,
those that felt confident and believed there were unlikely to fall may
engage in risky behaviors to meet their needs. Likewise, Haines, Lee,
O’Connell, McDermott, and Hoffman (2015) found delayed assistance
when requested or within an expected timeframe often lead to risk
taking. Previous studies suggest 45–64% of inpatient falls are related to
toileting (Zhao & Kim, 2015). However, acceptable response times may
vary between patients and situations. These findings should underscore
the importance of creating strategies to meet patients’ needs around
toileting. Several strategies may be used including a focus on decreasing
call light response times. In addition, units should consider proactive
ways to meet patient needs including structured nursing rounding on
fall prevention (Tucker, Bieber, Attlesey-Pries, Olson, & Diekhising,
2012). Structured rounding, which includes specific nursing actions,
aims to meet patient needs proactively through 1 or 2 hourly rounds.
While these studies support the implementation of rounding as a fall
prevention strategy, a study by Tucker et al. (2012), suggest patient and
clinician perspectives are important to consider when implementing
into practice. Hospital leaders need to create a shared purpose and
allow for tailoring of the intervention to meet unique patient needs and
nurse judgment (Goldsack, Bergey, Mascioli, & Cunningham, 2015;
Tucker et al., 2012).
8. Limitations
Whereas this study adds to the body of knowledge related to fall
prevention, there are limitations. We interviewed patients in non-ICU
settings in a single center which may limit generalizability. All parti-
cipants spoke English and we cannot comment on any ethnic or cultural
differences in perceptions. During the study period, the facility piloted
and spread standard work for fall prevention processes. Part of the
standard work that could have impacted the study the most was the
intentional patient communication regarding fall risk, use of white
board communication, and the standardization of equipment usage
such as alarms and gait belts. These interventions were put into place
after a third of our interviews were completed however our results may
have been impacted by this initiative. It is likely that many hospitals
have a focus on falls that may impact emerging literature. While cog-
nitive impairment contributes to fall risk, this study does not shed any
light on patient and family-centered strategies that may decrease fall
risk in this scenario.
9. Conclusion
Decreasing patient falls continues to be high priority for healthcare
organizations. Most fall prevention programs utilize clinician-led plan
development and implementation without true patient involvement.
Current fall prevention programs are well intentioned but may fail in
practice because of the mismatch between our view and those of the
patients. The fall assessment needs a shift from being clinician-centric
to patient-centric. More research is needed to develop and validate an
inpatient self-assessment tool that may help the patient recognize both
their overt and covert risk factors and become a more active and ac-
cepting participant in the plan. Nurses must develop a relationship with
the patient to facilitate understanding of their needs and how we can
focus on maintaining their sense of freedom. Developing these truly
patient centered programs may reduce the over-reliance on bed alarms
and allow for implementation of strategies aimed at mitigating mod-
ifiable risk factors leading to falls.
Declarations of interest
None.
Acknowledgements
The authors would like to thank Jennifer Dunscomb, Mary
Sitterding, Renee Twibell and Sue Lasiter for their support in the de-
velopment of this manuscript.
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