Hospitalized Patient Perception on Fall Risks and Prevention.

Hospitalized adults are more prone to falling during acute hospitalizations for a number of reasons. Acuity of illness, history of falls, clinical presentation such as confusion, unfamiliar environment, medications, age, mobility, gait, strength, physiological impairments and medical equipment, tubes, and lines directly contribute to an increase risk of falls along with other factors. Part of the nursing assessment is to assess the risk for falls and implement nursing interventions to prevent these from occurring. Regardless of nursing assessments and interventions, “hundreds of thousands of patients fall in hospitals, with 30-50% resulting in injury,” prolonging hospitalization time for an additional “average cost of $14,000” (The Joint Commission, 2015). Although not all falls result in injury, “falls with serious injury are consistently among the Top 10 sentinel events reported to The Joint Commission’s Sentinel Event database” with 63% “reported falls with injuries since 2009” resulting in death (The Joint Commission, 2015). When assessing patients for fall risks, however, patient perception on fall risks are not commonly assessed or addressed. In order to attempt to understand patient behavior, and involvement in care in regards to fall prevention patient perception should be assessed. For alert acutely-ill hospitalized adults, does the use of nursing fall risk assessments in combination with assessment of patient perceptions on falls, decrease the incidence of falls by promoting patient involvement in fall prevention?

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A research study conducted at Indiana University Health Ball Memorial Hospital surveyed 158 acutely-ill hospitalized consenting patients using a 38 item survey measuring confidence, fear, consequences and patient intent for engagement related to falls. Using the Intention Scale, “more than 75% of a participants reported they would call for assistance before getting out of bed” (Twibell, Siela, Sproat, & Coers, 2015). Fall prevention is the responsibility of both the nurse and patient, therefore patient engagement in their safety by working with the nurse and staff can decrease the incidence of falls. Although it is undetermined if the percentage is accurate due to the survey increasing patient’s exposure to the risk of falls, this information can be used to further assess the patient perception post fall prevention education. A relationship between patient perceived fall risk and anticipation of fall outcomes was identified. Patient anticipation of fewer negative outcomes of falls was higher in patients with perceived low fall risks and fear of falling (Twibell et al., 2015). Patients with a history of falls reported a perceived higher risk of falling and increased fear of reoccurrence. Fear of falling was associated with a higher patient intent of engagement in fall prevention by encouraging patients to request help before attempting to get out of bed. To promote patients to call before attempting to get out of bed and ensure safety, nurses should prevent from delaying responses to call lights, and addressing needs including toileting prior to leaving patient rooms. Nursing fall risk assessments should be conducted routinely as fall risk changes with patient condition. Perception assessments allow for the identification of teaching opportunities. Patient education regarding fall prevention should be individualized based on patient perception, bringing attention to the hazards of falling without increasing anxiety. Patients reported higher perceived consequences of falling as pain and difficulty getting up rather than serious injuries or morbidity (Twibell et al., 2015). Perceived vulnerability influenced patient behaviors and intent to participate in self-care (Twibell et al., 2015). Therefore, the higher the perceived threat of falling, the more cautious and determined patients are when preventing falls.

Reliability in a study is determined by ensuring consistency and repeatability in measuring tools by calculating the random error (Grove, Gray, & Burns, 2015). In critiquing the reliability of the Twibell et al. (2015) article, a 38 item survey was created using 4 scales, 3 scales developed, for this study and 3 single items, following a pilot study. Internal consistency reliability was established with the additional use of the Falls Efficacy Scale-International, the Falls Efficacy Scale, and the Consequences of Falling Scale for data as well as the Mini-cog examination and the Confusion Assessment Method to assess for eligibility for the study and rule out cognitive impairment (Twibell et al., 2015). Cronbach’s alpha was calculated for each scale and measured at 0.94 for the Confidence Scale, 0.95 for the Fear Scale, 0.90 for Intention Scale, and 0.84 for the Consequence Scale (Twibell et al., 2015). Scales used were considered reliable tools, as Cronbach’s alpha coefficients between 0.80 and 1.00 indicate high reliability (Grove et al., 2015). Collection of data was done verbally using visual scales, or with pen and paper during patient hospitalization. Collection method and the scales used for the study were both reliable.

Validity is determined by how the findings of the study represent the claims being made, and the degree of validity of the tools used for the particular study measurement. In critiquing the validity of Twibell et al. (2015) study, using a correlational design, content validity was identified by evaluating the tools used for measurement, and their relevance to the overall “construct being measured” and assessed (Grove et al., 2015). The scales used were valid for measurement, as they were directly relevant to the research, measuring patient perceptions related to falls and how these were related to patient engagement in fall prevention, and were developed following review by a panel of experts (Twibell et al., 2015).

In critiquing the Twibell et al (2015) study weaknesses and strengths were identified. A convenience sample using only a single- site, University Health Ball Memorial Hospital, a teaching hospital, was used. This limits the ability to control biases, increases possibility of sampling errors, and allows for the author’s ability to identify trends rather than arrive to generalized conclusions (Grove et al., 2015). Another weakness identified, was the lack of the author’s to specify the time during hospitalization when the survey was given. Responses may vary due to varying degrees of exposure to patient education, and patient-nurse relationships. Also, some questions were left unanswered by patients. Power analysis and number of participants identified a strength in the study. In order to achieve an 80% power analysis, a sample size of 150 to 180 patients would be ideal, and the study used 158 participant (Twibell et al., 2015). All surveys used had a Cronbach’s alpha close to 1.0 and greater than 0.80 identifying them as reliable tools which can be used for replication and additional research related to the topic.

In the Falls: Assessment and Prevention of Falls in Older People on the National Institute for Health and Care Excellence website, the importance of multifactorial assessment of risk factors, including the assessment of perceived functional ability and fear are emphasized (National Institute for Health and Care Excellence [NICE], 2013). Based on perceived weaknesses and fear, nurses can help the patient to participate in interventions aimed at addressing identified individual risk factors, by teaching them how to use call lights, when to ask for assistance, and including family in education (NICE, 2013). By implementing individualized multifactorial interventions such as referrals for impairments, review of medications, exercise and training and education, adequate management can prevent incidence of falls, minimize injuries and sentinel events, improve patient outcomes and optimize patient safety (NICE, 2013). Nurses in acute care settings should engage patients in identification of risk factors and interventions, but it is the nurse’s role to properly assess and continue reassessing throughout patient hospitalization.

Reassessment includes identifying environmental factors in the hospital setting. The Morse Scale is a recognized uniform scale used internationally identifying the risk of falling using six criteria as low, medium, or high based on numeric values without assessing patient perception. By comparing the numeric values, fall risk trend can be tracked and preventive interventions implemented as necessary (Sakai, Rossaneis, Fernandez Lourenco Haddad, & Williamowius Vituri, 2016). Although patients may feel confident and perceive a low risk of falling, hospitals are unfamiliar environments. Modifiable factors in these settings which patients ay not account for include accessibility and adequate space, obstacle-free paths, positioning of furniture, raised hospital beds, and use of medical equipment (Sakai et al., 2016). Cultural factors should also be addressed, as patients may also feel hesitant to ask for assistance due to perceived loss of independence and refusal of assistance (Sakai et al., 2016). Embarrassment, noncompliance, anxiety, and fear contribute to the risk of falling due to the hesitance of patients to ask for help.

In conclusion, for alert acutely-ill hospitalized adults, does the use of nursing fall risk assessments in combination with assessment of patient perceptions on falls, decrease the incidence of falls by promoting patient involvement in fall prevention? Patient involvement and compliance is essential for promoting safety. Patient perception to falling is directly related to participation in fall preventing behaviors. With proper assessments and identification of risk factors, appropriate interventions can be made. Through education, fear of falling can be addressed, and patients can be encouraged to participate in their care. It is recommended that fall risk assessments include patient perceptions, due to differences in perceived patient experience with falls varies as demonstrated by the study. As per recommended guidelines, assessments should include fall histories, which increase patient fear and perceived vulnerability. Continued reassessment during hospitalization is essential, as patient condition changes. Although protocols exist in hospital settings to prevent falls, additional assessments and continuous fall prevention education and awareness may help prevent future falls.

References

Grove, S. K., Gray, J. R., & Burns, N. (2015). Understanding nursing research: Building an evidence-based practice (6th ed.). St. Louis, MO: Elsevier.

National Institute for Health and Care Excellence. (2013, June 33). Falls: Assessment and prevention of fall in older people. Clinical guideline, 161. Retrieved from https://www.guideline.gov/summaries/summary/46931/falls-assessment-and-prevention-of-falls-in-older-people?q=fall

Sakai, A. M., Rossaneis, M. A., Fernandez Lourenco Haddad, M. C., & Williamowius Vituri, D. (2016, November 6). Risk of bed fall in adult patients and prevention measures. Journal Of Nursing UFPE / Revista De Enfermagem UFPE, 10(11), 4720-4726. http://dx.doi.org/10.5205/reuol.8200-71830-3-SM.1006sup201602

The Joint Commission. (2015). Preventing falls and fall-related injuries in health care facilities. Sentinel Event Alert, 55, 1-5. Retrieved from http://www.jointcommission.org/assets/1/18/SEA_55.pdf

Twibell, R. S., Siela, D., Sproat, T., & Coers, G. (2015, September ). Perceptions related to falls and fall prevention among hospitalized adults. American Journal of Critical Care, 24(5), 78-85. http://dx.doi.org/10.4037/ajcc2015375

Hospitalized Patient Perception on Fall Risks and Prevention.