What is The Role of Nurses in Fall Prevention

What is the role of nurses in fall prevention and the care of fall risk patients in hospital?

Is the increase in patient falls in hospital due to increased nursing workload?

Background (Learning Outcomes 1 and 2)

LO1 Critically analyse the context of nursing practice and its contemporary influences

LO2 Synthesise service improvement strategies to formulate a business case or research proposal for sustainable health care

The rationale for this area of interest is that falls are the most common causes of unintentional injuries resulting in over 646,000 deaths world-wide each year especially among adults aged 65 and over. According to various studies, the rate of falls in hospitals around the United Kingdom (UK) is high with research reporting rates of 18 falls per 1000 occupied beds day (Cooper et al, 2021), falls can result to reduction in quality of life, mortality, and prolonged hospitalisation (Child et al, 2012). Falls as well as fall-related injuries are common among older people with 30% of people older than 65 and 50% people older than 80 falling at least once a year (NICE, 2013). A fall can be defined as an event in which a person comes to rest inadvertently on the ground, floors, or other levels (Cooper et al, 2021).

Risk factors for falls in hospitalised patients included: advanced age, gait instability, confusion, adverse drug reactions, recent fall, structural, staffing and nurse level factors (Bowden, Bradas & McNett, 2018) (Morris & O’Riordan, 2017). Research indicates that falls cost between 1.6% and 13.4% of the annual income in acute care hospitals and 0.85% and 1.5% of the total health care expenses within the UK, European Union (Montejano-Lozoya et al, 2020). Personal experience during my placement on a medical surgical ward highlighted that the shortage of registered nurses to care for acutely ill pateints put them more at a risk of experiencing falls. This was mainly due to the fact the nurses on duty had to fill the gap which ncreased their workload and and stress levels increased when they were short of nursing staff in taking part in falls prevention and caring for patients at a risk of falls during my placement on medical surgical ward highlighted the huge role played by of nurses in preventing falls and caring for patients at a risk of falls which included carrying out patient risk assessments, ensuring all call bells were within reach to the patients, following organisational policies such as bay watching for high risk patients, communicating to patients about the possibility of falls due to their health conditions.

According to Bowden, Bradas & McNett, (2019) patient falls are an important safety concern for nurses and patients themselves internationally. Nurses are directly responsible for meeting the hospital no fall goal, identifying, and caring for patients at a risk of falls and implement fall prevention programs allowing very positive results to be obtained (Montejano-Lozoya et al, 2020). A study by King et al, (2016) indicates that nurses express increased stress, anxiety, self-doubt about the quality of care they provide when falls occur hence making them a second victim. Therefore, the purpose of this study to examine the fall prevention strategies and interventions by nurses in care settings.

The context of nursing practice is the duty of care in which nurses must make patients’ care and safety their main concern, and ensuring that patients’ needs are recognised, assessed, and responded to (Dowie, 2017). Nurses have a duty of preventing harm during the provision of care in both long and short-term care setting by adhering to organisational strategies for identifying harms and risks through assessing and planning patient care, monitoring, offering assistance, and communicating with other healthcare professionals (Vaismoradi et al, 2020). However according to (Bowden, Bradas & McNett, 2019) poor nurse self-efficacy, knowledge deficits, elevated stress levels of nurses as well as level of experience and educational background can all contribute to the increase of inpatient falls. Also, the perception of patient safety culture among nurses in small/medium hospital is low indicating that the perception of patient safety culture by nurses varies according to the size of hospital (Cho & Jang, 2020). Hence patient safety in hospitals can be enhanced by researching and developing nursing practice guidelines for preventing inpatient falls and caring for risky patients while providing appropriate motivation.

Recent health research indicates that nurses are the professionals responsible for performing patient assessments upon admission to hospital hence they are in position to identify at a high/low risk and implementing evidence-based fall prevention interventions (Montejano-Lozoya et al, 2020) to improve patient safety. According to recent study by ( ) nurses’ education and a fall prevention program are both important in preventing falls. According to a recent study by Cooper et al, (2021) health technologies can be used in the prevention of falls and care of risk patients. Health technologies can be defined as the application of organised knowledge and skills in the form of devices, machines, systems developed to solve health problems to improve quality of life (). Health technologies used in hospitals to prevent falls include: patient and staff education, intention Additionally, nurses have a great impact on reducing patient falls due to their consistent contact with patients and continuous monitoring them for conditional changes as well as recognition of deterioration (King et al, 2016). However recent studies show that they are nurse-specific factors that contribute to patient falls such as nursing stuff and their preparedness to care for patients at a risk and lack of caring attitude (Bowden, Bradas & McNett, 2018). Also, (Pham et al, 2020) suggests that the moderate nursing knowledge and practice in fall prevention contributes to patient falls.

The background section should include:

A rationale for the choice of using a research proposal for service improvement

How the area of interest for service improvement relates to nursing practice

A critical analysis of a context of nursing practice related to the area of interest

A critical analysis of a contemporary influences related to the area of interest

How the area of interest relates to sustainability

Literature Review (Learning Outcome 3)

LO3 Identify and critically appraise the evidence base used to support a business case or research proposal

A literature review is a comprehensive study and interpretation of literature that relates to a particular question (Aveyard, 2018). Hence, the objective of completing this literature review is to identify the fall prevention strategies and interventions used by nurses in care settings due to a wide variability in falls rates reported in recent literature of 18 falls per 1000 occupied beds day (Copper et al, ) by appraising and analysing relevant literature.

I conducted a review of literature published between 2010 and 2021 using the PEO framework which stands for Population, Exposure and Outcome on qualitative and quantitative research studies on fall prevention strategies and interventions by nurses in care settings. The following database were searched; PubMed, Evidence Search by NICE, TRIP database and reference lists of articles for studies published in English and peer reviewed. Exclusion criteria included: all grey literature, studies on falls prevention in community based, studies from 2009 below, people of 59 years and below and physical disabilities. Of the 16 articles identified, 6 were included in the review. A meta-analysis of the 6 studies revealed that there are various strategies and intervention studies on fall prevention in care settings.

Discussion

Various researchers have examined the issue of falls in the quest of trying to understand the causes and thus propose the most effective interventions for curbing the same. Studies have reported falls to be amongst the safety issues that are faced by inpatients in hospitals. Other researchers have reported that averagely 6.63 falls are experienced every a thousand beds that are occupied in hospitals. This is indicates that more than 1700 falls are thus experienced annually making falls a major issue that needs apt address. Apart from the problems that patients experience as a result of falls such as harms and injuries, other researchers have documented that also psychological distress is experienced by patients as a result of falls.

Ambrose et al. (2013) examined the risk of falls in hospitals. Besides, the researchers studies have undertaken a comparison between the falls that are experienced in hospitals and those experienced at community levels where by a similarity has been reported. Besides, the risk factors have also been noted to be similar and they are inclusive of advanced age that is above 85 years meaning that falls are more prevalent among the elderly population (Ambrose et al., 2013). Besides, male sex is noted to be at a higher risk of falls relative to their female counterparts. Also, patients or community members with history of a previous recent fall are also at a higher risk of falling again just like individuals suffering from instability of the gait. Adverse drug interactions and neurocardiovascular instability has been greatly associated with higher risk of falls among inpatients (Ambrose et al., 2013). Fall risk scores in hospitals have been estimated through the use of combination of risk factors. There have also been hopes of focusing prevention efforts on the patients who are at higher risk of falling. Just like in various interventions, nurses are at the forefront of these activities (Ambrose et al., 2013).

Loganathan et al. noted from their study that the efforts by nurses to reduce falls have been faced by various limitations and barriers (2015). The multiprofessional intervention that involves nurses amongst other healthcare practitioners has faced by various challenges within general hospital settings. There has been an increased number of falls in acute care hospitals (Loganathan et al., 2015). The consequences of the same have been detrimental and sometimes can be inclusive of severe injuries or sometimes death. Increased workloads have been suggested as one of the factors that has affected the role of nurses in preventing falls in acute care hospitals. Fall prevention has been a developing interest in care institutions and more so for the adult population. In older adult patients, falls have been reported to be the leading cause of injuries (Loganathan et al., 2015). Besides, the results are usually costly not only for patients but also for the healthcare practitioners. Reports by other researchers have suggested that falls are experienced more and the rates of injuries are equally more (Loganathan et al., 2015).

According to Dickinson et al. (2011), falling is not normality in the aging process but a serious health concern that calls for apt address. However, researchers have reported the existence of age-related changes that exposes adults to relatively more cases of falls. These are inclusive of poor muscle strength, as well as reduced strengths in the lower parts of the body (Dickinson et al., 2011). Other age-related factors that put adults at risk of falls is inclusive of postural reduced blood pressure, loss of vision, balance abnormalities, and uncomfortable footwear amongst other factors. Consequences of falls are more serious in older patients compared to other age group of patients in healthcare settings. Patients have lost their functional ability as a result of falls besides experienced surged early admissions to nursing homes alongside heightened medical expenditures (Dickinson et al., 2011). The researchers also noted that fall prevention is considered as a duty of professionals from different disciplines but nurses are still at the fore front of the campaign as they spend the most time with the patients. The duties of the nurses in preventing fall prevention has also been noted to be based on the configurations of healthcare practitioners as well as the management decisions that are carried out by nurses in preventing falls (Dickinson et al., 2011). It is the duty of nurses to not only complete but also document patient falls risk as well as risk assessments for the patients. Besides, nurses are presented with the duty of recording fall-prevention practices that are specific to particular patients. Also, nurses follow-up on the medical conditions of patients and monitoring any changes that can be observed in the course of stay at the hospital. In case of fall incidences, the nurse is obligated to report such situations to the physicians. They need to acquire medical orders from physicians as expected of them. Another nursing role in fall prevention is supervision of nursing aides as well as the education of patient and families on fall prevention strategies (Dickinson et al., 2011).

From the study by Wiseman et al. (2021), they have noted that while in practice, nurses have been noted to apply prevention strategies that have mostly been patient specific. For instance, in cases whereby the patient had fallen in the past, most of the nurses have been noted to get engaged in the potential cause of the previous falls and designing potential strategies that can be useful in preventing future occurrences of the same (Wiseman et al., 2021). Other researchers report that when patients were noted to have unstable walking gait, nurses ensured that the patient had access to mobility aids when they are need of the same (Dickinson et al., 2011). Besides, they also ensured that patients were always putting on non-slip shoes as a precaution for avoiding falls. Gait belt assists have also been used by patients during ambulation besides making sure that physical therapy is part of daily schedules of the patients. In patients with urinary incontinence, nurses have curbed that by ensuring that their patients had a strict toilet schedule that they would then follow (Wiseman et al., 2021).

According to Vlaeyen et al., 2017, managing falls among the elderly has been more challenging owing to their multifactorial nature. For instance, factors that have contributed to the same are inclusive of environmental factors, home hazards for home falls, as well as poor health and functional incapacities. Nurses have in the past came up with effective interventions to reduce or manage falls among older adults but implementation of the same has not been easy as a result of the diverse challenges and barriers that they face (Vlaeyen et al., 2017). Some of the interventions that have been suggested by nurses include multi-component physical fitness activities, hazard modifications at home, medication reviews, as well as multifaceted fall intervention programs. On the other hand, barriers have been noted to be inclusive of lack of compliance by patients as well as shortage of healthcare professionals to deliver coordinated care for the patients and population at risk (Vlaeyen et al., 2017). Apart from these, the researchers have associated limitation to prevention of falls by nurses with lack of reimbursement for effective patient referral (Vlaeyen et al., 2017).

LeLaurin and Shorr undertook a study to examine prevention of falls in hospitalised patients (2019). One of the interventions that they reported from their study was fall risk identification. According to them, the usage of the tool has seen a great advancement of the years. Besides, the authors noted that the value of the tool in fall prevention has faced significant criticism and thus is greatly questionable. In assessing the effectiveness of the tool, the authors not that, nurses are obligated to be able to differentiate fall risk assessment from prediction or screening tools. Risk assessment involves looking into the risk factors that patients are predisposed to while hospitalized. The predictive tools thus make use of the risk factors in the calculation of the possibilities of a patient falling (LeLaurin and Shorr, 2019).

Trivialisation of falls has been noted as one of the barriers faced by healthcare practitioners since in most cases, there is an under-assessment of cases of falls as most healthcare practitioners fail to realise the seriousness of falls and thus do not treat it as a priority (Wiseman et al., 2021). Another barrier has been the lack of clinical skills in managing falls. For instance, nurses often perceive that they do not have the knowledge and the skills that are necessary in the management of falls. Besides, some nurses are unaware of the importance that exercise has on the prevention of falls among older patients. Besides, most nurses also lack the knowledge of the contribution that hearing problems has on surging the risk of falls (Wiseman et al., 2021). Poor or lack of interprofessional communication within healthcare settings has also been a major barrier to prevention of falls by nurses as well as other healthcare practitioners. Nurses are overloaded thus, coordination of care has been necessary to effectively prevent falls among patients (Wiseman et al., 2021). Independent working of healthcare practitioners has made fall prevention quite difficult. Following the continued experience of falls in hospitals, the role of nurses in the prevention of the same has not been well understood. Besides, the question of whether work overload has contributed to increased incidences of falls has not been well investigated thus leaving a gap that my research question aims to fill.

Aims and Objectives (Learning Outcome 2)

LO2 Synthesise service improvement strategies to formulate a business case or research proposal for sustainable health care

The aim should outline:

the research question for the intended service improvement initiative

The objectives section should include and evidence-based discussion including:

A clear description of the proposed research

The proposed research design (method / recruitment / participants / ethical considerations)

The strengths of the proposed research design

How rigour will be ensured when conducting the research

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References:

Ambrose, A. F., Paul, G., & Hausdorff, J. M. (2013). Risk factors for falls among older adults: a review of the literature. Maturitas, 75(1), 51-61.

Dickinson, A., Horton, K., Machen, I., Bunn, F., Cove, J., Jain, D., & Maddex, T. (2011). The role of health professionals in promoting the uptake of fall prevention interventions: a qualitative study of older people's views. Age and ageing, 40(6), 724-730.

LeLaurin, J. H., & Shorr, R. I. (2019). Preventing falls in hospitalized patients: state of the science. Clinics in geriatric medicine, 35(2), 273-283.

Loganathan, A., Ng, C. J., Tan, M. P., & Low, W. Y. (2015). Barriers faced by healthcare professionals when managing falls in older people in Kuala Lumpur, Malaysia: a qualitative study. BMJ open, 5(11), e008460. https://doi.org/10.1136/bmjopen-2015-008460

Vlaeyen, E., Stas, J., Leysens, G., Van der Elst, E., Janssens, E., Dejaeger, E., ... & Milisen, K. (2017). Implementation of fall prevention in residential care facilities: A systematic review of barriers and facilitators. International journal of nursing studies, 70, 110-121.

Wiseman, J. M., Stamper, D. S., Sheridan, E., Caterino, J. M., Quatman-Yates, C. C., & Quatman, C. E. (2021). Barriers to the initiation of home modifications for older adults for fall prevention. Geriatric orthopaedic surgery & rehabilitation, 12, 21514593211002161.

Appendices:

Include all the tables and charts used to support the literature review, as a ‘separate’ appendix e.g

Appendix 1: Table of PEO framework

Appendix 2: Databases Used for the Literature Search with Rationale

Appendix 3 etc…