Fall Prevention Decision Making of Acute Care Registered Nurses

Selecting and tailoring implementation strategies for deimplementing fall prevention alarms in US hospitals: a group concept mapping study

OBJECTIVES

Many hospitals use fall prevention alarms, despite the limited evidence of effectiveness. The objectives of this study were (1) to identify, conceptualise and select strategies to deimplement fall prevention alarms and (2) to obtain feedback from key stakeholders on tailoring selected deimplementation strategies for the local hospital context.

METHODS

Hospital staff working on fall prevention participated in group concept mapping (GCM) to brainstorm strategies that could be used for fall prevention alarm deimplementation, sort statements into conceptually similar categories and rate statements based on importance and current use. Hospital staff also participated in site-specific focus groups to discuss current fall prevention practices, strategies prioritised through GCM and theory-informed strategies recommended by the study team, and potential barriers/facilitators to deimplementing fall prevention alarms.

RESULTS

90 hospital staff across 13 hospitals brainstormed, rated and sorted strategies for alarm deimplementation. Strategies that were rated as highly important but underutilised included creating/revising staff roles to support fall prevention (eg, hiring or designating mobility technicians) and revising policies and procedures to encourage tailored rather than universal fall precautions. 192 hospital staff across 22 hospitals participated in site-specific focus groups. Participants provided feedback on each strategy's relevance for their site (eg, if site currently has a mobility technician) and local barriers or facilitators (eg, importance of having separate champions for day and night shift). Findings were used to develop a tailored implementation package for each site that included a core set of strategies (eg, external facilitation, education, audit-and-feedback, champions), a select set of site-specific strategies (eg, designating a mobility technician to support fall prevention) and guidance for how to operationalise and implement each strategy given local barriers and facilitators.

CONCLUSION

Findings from this study can be used to inform future programmes and policies aimed at deimplementing fall prevention alarms in hospitals.

Investigating nurses' attitudes towards the prevention of falls: A mixed-method study

The purpose of this study was to investigate nurses' attitudes towards prevention of falls using the Nurses Attitudes Towards Prevention of Falls Scale and to identify factors affecting these attitudes. A mixed-method design was applied and a convenience study was conducted. Six-hundred and thirty nurses participated. In the first stage of this study, the psychometric properties of the Nurses' Attitudes Towards Prevention of Falls Scale were tested. Quantitative data were collected using the Introductory Information Form and the Nurses' Attitudes Towards Prevention of Falls Scale. While collecting this data, 24 nurses were interviewed. The Nurses' Attitudes Towards Prevention of Falls Scale was determined to be a valid and reliable measurement tool. Most of the participating nurses did not complete a fall incident report when their patients experienced a fall, and that led to nurses experiencing remorse, fear, guilt, sadness, anxiety, and panic when their patients fell.

The knowledge, attitude, and practice toward fall prevention of parturients in the obstetric inpatient wards: a comparative cross-sectional study between nurses and parturients

Objective

This study aimed to compare the knowledge, attitudes, and practices of parturients and nurses regarding fall prevention among parturients, with the goal of understanding the cognitive factors contributing to post-delivery fall.

Methods

A cross-sectional survey was conducted among obstetric nurses and women in obstetric ward within 2 days after vaginal delivery. The survey instrument included a self-design questionnaire comprising a demographic information sheet and a KAP questionnaire, which demonstrated acceptable reliability and validity.

Results

A total of 705 nurses and 1,220 parturients completed the survey. Over half of both nurses and parturients exhibited reasonably good knowledge, positive attitudes and appropriate practices related to fall prevention. Significant associations were identified between the education level of parturients and their knowledge and attitudes. Nurses scored lower in the attitude dimension compared to parturients (4.32 ± 1.01 vs. 4.84 ± 0.36, P < 0.001), whereas nurses scored higher than parturients in the practice dimension (3.76 ± 0.44 vs. 3.57 ± 0.48, P < 0.001).

Conclusion

Nurses should focus on enhancing the fall practices of parturients by emphasizing key points for fall prevention and providing guidance in situations of improper behaviors (e.g., unaccompanied activities). Further education programs for nurses should prioritize increasing their confidence and proficiency in fall prevention.

Fall risk factors and mitigation strategies for hematological malignancy patients: insights from a qualitative study using the reason model

PURPOSE

Our study aim was to understand the (human and organizational) factors influencing fall risk among people with hematological malignancies using the Reason model as a framework, providing insights that can inform the development of safe and effective fall management strategies.

METHODS

Purposive sampling was employed to conduct semi-structured interviews with 13 people with hematological malignancies and 12 nurses from the hematology department of a tertiary grade A hospital in Guangzhou from December 2023 to February 2024. The topic analysis method was utilized to analyze the interview data.

RESULTS

Factors influencing fall risk among people with hematological malignancies were categorized into four themes: (1) precondition of unsafe arts (lack of work experience in junior nurses, poor patient compliance, adverse drug reactions, inadequate ward facilities); (2) unsafe supervision (inadequate inspection management, inadequate accompanying capacity); (3) unsafe arts (variability in subjective assessment, lack of bidirectional education); and (4) organizational influences (limited nursing human resources, lack of organizational process management models).

CONCLUSION

The specific fall risk factors among people with hematological malignancies, as summarized based on the Reason model framework, provide a theoretical basis and direction for the construction of specialized fall risk assessment tools, aiming to improve the quality of fall management for inpatients and reduce the incidence of falls.

Multifactorial fall interventions for people over 65 years in the acute hospital setting: pre-post-test design

BACKGROUND

Falls are the most reported patient safety incident for patients >65 years in acute hospital settings worldwide. While multifactorial fall interventions reduce the number of falls in subacute and rehabilitation settings, fall interventions in acute hospital settings are unknown.

AIM

To evaluate the effectiveness of multifactorial fall interventions on the number of falls using codesigned education targeting staff and the patient and review the environment in acute hospital settings in NSW, Australia for patients over 65 years of age.

METHOD

A pre-post-test design with a non-equivalent group was conducted. All acute hospital inpatient falls occurring both pre- and post-intervention within one health district were included in this study. The use of Quality Improvement methodology identified gaps in risk screening and assessment, education and information, communication of risk, and standardised fall prevention equipment. Codesigned interventions to address these gaps were undertaken.

RESULTS

The number of falls (p = 0.038) and injurious falls (p < 0.001) significantly decreased in the post-intervention group. There was a significant improvement in fall assessments (p < 0.001), delirium risk screening (p < 0.001), the provision of fall information (p < 0.001) and fall risk discussed at shift handover (p < 0.001) in the post-intervention group. Following the intervention, staff were significantly more likely to undertake fall education modules (p < 0.001) and develop a fall management plan (p < 0.001).

CONCLUSION

Falls continue to have a significant economic impact on the acute hospital setting. Our findings highlight multifactorial fall interventions that included staff and patients in the development phases reduced the number of falls. Multifactorial fall interventions targeting staff, patients and the environment may influence a reduction in the number of falls and the severity of falls in the acute hospital setting.

IMPACT STATEMENT

Multifactorial fall interventions reduce injurious falls, minor injuries, and falls resulting in serious injury and death.

Investigating clinical decision-making in bleeding complications among nursing students: A longitudinal mixed-methods study

AIM

To describe undergraduate nursing students' clinical decision-making in post-procedural bleeding scenarios and explore the changes from the first to the final year of their program.

BACKGROUND

Bleeding is a common complication following invasive procedures and its effective management requires nurses to develop strong clinical decision-making competencies. Although nursing education programs typically address bleeding complications, there is a gap in understanding how nursing students make clinical decisions regarding these scenarios. Additionally, little is known about how their approach to bleeding management evolves over the course of their education.

DESIGN

Longitudinal mixed-methods study based on the Recognition-Primed Decision Model.

METHODS

A total of 59 undergraduate students recorded their responses to two clinical decision-making vignettes depicting patients with signs of bleeding post-hip surgery (first year) and cardiac catheterization (final year). Their responses were analyzed using content analysis. The resulting categories capture the cues students noticed, the goals they aimed to achieve, the actions they proposed and their expectations for how the bleeding situations might unfold. Code frequencies showing the most variation between the first and final years were analyzed to explore changes in students' clinical decision-making.

RESULTS

Nearly all students focused on two primary categories: 'Bleeding' and 'Instability and Shock.' Fewer students addressed six secondary categories: 'Stress and Concern,' 'Pain,' 'Lifestyle and Social History,' 'Wound Infection,' 'Arrhythmia,' and 'Generalities in Surgery.' Students often concentrated on actions to manage bleeding without further assessing its causes. Changes from the first to the final year included a more focused assessment of instability and shifts in preferred actions.

CONCLUSIONS

This study reveals that nursing students often prioritize immediate actions to stop bleeding while sometimes overlooking the assessment of underlying causes or broader care goals. It suggests that concept-based learning and reflection on long-term outcomes could improve clinical decision-making in post-procedural care.

Exploring nurses' clinical judgment concerning the relative importance of fall risk factors: A mixed method approach using the Q Methodology

BACKGROUND

Nurses are pivotal in averting patient falls through their assessment of cues presented by patients and their environments, rendering clinical judgments regarding the risk of falling, and implementing tailored interventions. Despite the intricate cognitive processes entailed in nurses' judgment, no prior studies have explored their approach to assessing the risk of falling.

OBJECTIVE

This study aimed to examine how nurses judge the risk of falling among patients with different conditions, whether there are differences in the importance of risk factors as judged by nurses, how they justify their judgments, and what attributes of the nurses influence their judgments.

DESIGN

A mixed method approach using the Q Methodology was employed.

SETTING(S)

Three public and private hospitals in Japan.

PARTICIPANTS

Eighteen nurses participated in the study.

METHODS

Participants were tasked with ranking 36 patient scenarios, each featuring a distinct set of fall risk factors. Subsequently, post-sorting interviews were conducted to gather insights into their typical approach to assessing fall risk and the rationale behind their ranking decisions. A by-person principal component factor extraction was employed to examine differences in the rankings of the scenarios. The interview data were analyzed descriptively to elucidate the reasons behind these discrepancies.

RESULTS

Nurses engage in complex cognitive manipulations when evaluating the risk of patient falls, drawing extensively from their wealth of experience while utilizing assessment tools to support their judgments. In essence, nurses identify patients' tendency to act alone without calling a nurse, impaired gait and cognition, sedative use, drains, and limited information sharing among healthcare professionals as key fall risks. In addition, nurses vary in the importance they attribute to certain risk factors, leading to the discrimination of three distinct judgment profiles. One group of nurses judges patients with cognitive impairment and acting alone as high risk. Another group of nurses considers patients with unstable gait and acting alone as high risk. The last group of nurses sees patients wearing slippers as high risk. The post-sorting interviews revealed that their judgments are closely related to the healthcare context and patient population.

CONCLUSIONS

Nurses operate within diverse contexts, wherein they interact with patients of varying characteristics, collaborate with professionals from diverse disciplines, and have access to varying levels of human and physical resources. This nuanced understanding empowers the formulation of judgments that are finely attuned to the specific context at hand.

STUDY REGISTRATION

Not registered.

Alarm with care-a de-implementation strategy to reduce fall prevention alarm use in US hospitals: a study protocol for a hybrid 2 effectiveness-implementation trial

BACKGROUND

Fall prevention alarms are commonly used among US hospitals as a fall prevention strategy despite limited evidence of effectiveness. Further, fall prevention alarms are harmful to healthcare staff (e.g., alarm fatigue) and patients (e.g., sleep disturbance, mobility restriction). There is a need for research to develop and test strategies for reducing use of fall prevention alarms in US hospitals.

METHODS

To address this gap, we propose testing the effectiveness and implementation of Alarm with Care, a de-implementation strategy to reduce fall prevention alarm use using a stepped-wedge randomized controlled trial among 30 adult medical or medical surgical units from nonfederal US acute care hospitals. Guided by the Choosing Wisely De-Implementation Framework, we will (1) identify barriers to fall prevention alarm de-implementation and develop tailored de-implementation strategies for each unit and (2) compare the implementation and effectiveness of high- versus low-intensity coaching to support site-specific de-implementation of fall prevention alarms. We will evaluate effectiveness and implementation outcomes and examine the effect of multi-level (e.g., hospital, unit, and patient) factors on effectiveness and implementation. Rate of fall prevention alarm use is the primary outcome. Balancing measures will include fall rates and fall-related injuries. Implementation outcomes will include feasibility, acceptability, appropriateness, and fidelity.

DISCUSSION

Findings from this line of research could be used to support scale-up of fall prevention alarm de-implementation in other healthcare settings. Further, research generated from this proposal will advance the field of de-implementation science by determining the extent to which low-intensity coaching is an effective and feasible de-implementation strategy.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT06089239 . Date of registration: October 17, 2023.

An Exploration of Critical Care Professionals' Strategies to Enhance Daily Implementation of the Assess, Prevent, and Manage Pain; Both Spontaneous Awakening and Breathing Trials; Choice of Analgesia and Sedation; Delirium Assess, Prevent, and Manage; Early Mobility and Exercise; and Family Engagement and Empowerment: A Group Concept Mapping Study

The goals of this exploratory study were to engage professionals from the Society for Critical Care Medicine ICU Liberation Collaborative ICUs to: 1) conceptualize strategies to enhance daily implementation of the Assess, prevent, and manage pain; Both spontaneous awakening and breathing trials; Choice of analgesia and sedation; Delirium assess, prevent, and manage; Early mobility and exercise; and Family engagement and empowerment (ABCDEF) bundle from different perspectives and 2) identify strategies to prioritize for implementation.

DESIGN

Mixed-methods group concept mapping over 8 months using an online method. Participants provided strategies in response to a prompt about what was needed for successful daily ABCDEF bundle implementation. Responses were summarized into a set of unique statements and then rated on a 5-point scale on degree of necessity (essential) and degree to which currently used.

SETTING

Sixty-eight academic, community, and federal ICUs.

PARTICIPANTS

A total of 121 ICU professionals consisting of frontline and leadership professionals.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A final set of 76 strategies (reduced from 188 responses) were suggested: education (16 strategies), collaboration (15 strategies), processes and protocols (13 strategies), feedback (10 strategies), sedation/pain practices (nine strategies), education (eight strategies), and family (five strategies). Nine strategies were rated as very essential but infrequently used: adequate staffing, adequate mobility equipment, attention to (patient's) sleep, open discussion and collaborative problem solving, nonsedation methods to address ventilator dyssynchrony, specific expectations for night and day shifts, education of whole team on interdependent nature of the bundle, and effective sleep protocol.

CONCLUSIONS

In this concept mapping study, ICU professionals provided strategies that spanned a number of conceptual implementation clusters. Results can be used by ICU leaders for implementation planning to address context-specific interdisciplinary approaches to improve ABCDEF bundle implementation.

Falls as the result of interplay between nurses, patient and the environment: Using text-mining to uncover how and why falls happen

Objectives

This study aimed to explore, from the perspectives of nurses, how patients, the environment, and the practice of nurses interact with each other to contribute to patient falls.

Methods

A retrospective review of incident reports on patient falls, registered by nurses between 2016 and 2020, was conducted. The incident reports were retrieved from the database set up for the project of the Japan Council for Quality Health Care. The text descriptions of the "background of falls" were extracted verbatim, and analyzed by using a text-mining approach.

Results

A total of 4,176 incident reports on patient falls were analyzed. Of these falls, 79.0% were unwitnessed by nurses, and 8.7% occurred during direct nursing care. Document clustering identified 16 clusters. Four clusters were related to patients, such as the decline in their physiological/cognitive function, a loss of balance, and their use of hypnotic and psychotropic agents. Three clusters were related to nurses, and these included a lack of situation awareness, reliance on patient families, and insufficient implementation of the nursing process. Six clusters were concerned with patients and nurses, including the unproductive use of a bed alarm and call bells, the use of inappropriate footwear, the problematic use of walking aids and bedrails, and insufficient understanding of patients' activities of daily living. One cluster, chair-related falls, involved both patient and environmental factors. Finally, two clusters involved patient, nurse, and environmental factors, and these falls occurred when patients were bathing/showering or using a bedside commode.

Conclusions

Falls were caused by a dynamic interplay between patients, nurses, and the environment. Since many of the patient factors are difficult to modify in a short time, the focus has to be placed on nursing and environmental factors to reduce falls. In particular, improving nurses' situation awareness is of foremost importance, as it influences their decisions and actions to prevent falls.

Patient-level and organizational-level factors influencing in-hospital falls

AIM

In-hospital fall is one key safety issue in a healthcare setting. Although healthcare providers apply several strategies for preventing falls, falls still occur in hospitals. The aim of this study was to investigate patient-level and organizational-level factors influencing in-hospital falls.

DESIGN

A multicentre retrospective observational study.

METHODS

This study used the national healthcare database and supplemented with organizational data obtained through a survey. Data extraction and survey were conducted between July and August 2020. A mixed-effect logistic regression model was used to analyse factors influencing in in-hospital falls.

RESULTS

A total of 43,286 patients admitted in 86 hospitals were included in this study. Fall rate was 0.85 per 1000 days. Length of stay was significantly longer for fall patients than for no-fall patients. Patient-level factors (including age, mobility impairment and surgery) and organizational-level factors (including nurse staffing and proportion of new nurses) were significant factors influencing in-hospital falls.

CONCLUSION

Since in-hospital falls increase economic burden to patients, we should consider various fall prevention strategies to reduce falls. For a strategy to be applied stably to patients, organizational factors must be supported.

IMPACT

Proactive fall management in acute settings is essential to ensure patient safety. Considering that the number of patients with fall risk is increasing due to ageing, organizational factors should be supported to provide quality nursing care for fall risk patients. Therefore, nurse leaders should primarily ensure an appropriate level of nurse staffing. They also need to make efforts to strengthen clinical competency of nurses.

Understanding the systemic influences on maritime pilot decision-making

Maritime incidents occurring during pilotage are of international concern. Maritime pilots control most pilotage operations worldwide, yet despite the safety criticality of their role, research examining pilot decision-making processes during these complex and dynamic operations is scarce. This article describes the findings from two studies that utilised an integrated systems thinking framework to understand how pilots make decisions and what factors are perceived to influence their decisions. Interviews were held with 22 pilots (Study 1) and 17 maritime safety stakeholders (Study 2) in the New Zealand maritime context. The findings illustrate the challenges pilots face during pilotage and provide insights into their decision-making processes and the systemic factors that can be addressed to improve maritime safety. Given the multiple causal pathways to incidents occurring during pilotage identified by this research, it is suggested that multiple systems-wide interventions are needed, which is likely to require a long-term, strategic approach.

Nurses' Perceptions of Recommended Fall Prevention Strategies: A Rapid Review

BACKGROUND

Limited studies have synthesized evidence on nurses' perceptions of recommended fall prevention strategies and potential differences between those and the practiced strategies.

PURPOSE

To synthesize evidence about nurses' perceptions of recommended fall prevention strategies for hospitalized adults.

METHODS

Using PubMed, 50 records underwent abstract and full-text screening, and 10 studies were retained. Narrative synthesis was conducted to identify common themes across studies. Quality assessment was not performed.

RESULTS

Nurses are aware of effective fall prevention strategies but identified unit-level barriers and facilitators to implementing these in their practice. Unit culture and policies, educational offerings, nursing interventions, and style of communication and collaboration were seen to influence fall prevention.

CONCLUSIONS

Nurses recognize falls as a multifactorial issue suggesting that prevention efforts be tailored to the unit and involve all employees. We recommend that future research emphasize identifying and understanding the combination of factors that produce successful unit-level fall prevention strategies.