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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: [email protected] (B. Radecki), [email protected] (S. Reynolds), [email protected] (A. Kara).

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0897-1897/ © 2018 Elsevier Inc. All rights reserved.

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& 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?

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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.

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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

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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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