FALL PREVENTION RESEARCH PAPER

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IN A STUDY OF THREE U.S. hospi-tals, the operational costs forpatients who fell with seriousinjury were $13,316 higher and length of stay 6.3 days longer than patients who did not fall (Wong et al., 2011). Spoelstra, Given, and Given (2012) conclud- ed multifactorial intervention pro- grams for fall prevention demon- strated a significant reduction in both falls and fall injuries among inpatients in hospital settings. Interventions included in Spo - elstra and associates’ study includ- ed fall risk assessments, fall risk alerts, modification of environ- ment or equipment, staff and pa - tient safety education, high fall risk medication management, and staff assistance with transfer and toileting as essential elements in fall prevention. In the current cost- constrained environment with high-acuity patients and challeng- ing total nursing hours per patient day ratios, understanding the effectiveness of fall prevention interventions identified in previ- ous literature and prioritizing them to improve clinical efficiency is urgently needed.

A study conducted of regis- tered nurses’ (RN) perceptions by Tzeng and Yin (2013) found nine of the top 20 most frequently adopted and effective fall preven- tion interventions were consistent:

(a) keeping hospital bed brakes locked, (b) keeping patient beds in low position, (c) maintaining a call light within reach, (d) keeping floor surfaces clean and dry, (e) reducing tripping hazards, (f) assessing and modifying environ- ment as needed, (g) adjusting lights to daily activities, (h) com- pleting a fall risk assessment at admission, and (i) keeping non- slip, well-fitted footwear on patients.

A study conducted by Tzeng and Yin (2015) found each hospi- tal inpatient specialty area had its own top 10 effective interventions identified by RNs. The complexity and differences in fall prevention across 10 identified specialty areas were evident. For example, only one common intervention (keep- ing hospital bed brakes locked) appeared in the lists from surgical and medical-surgical combined units. In contrast, five common interventions appeared in lists from medical units and medical- surgical combined units (keeping hospital bed brakes locked, offer- ing one-on-one support while patient is in the bathroom, main- taining call light within reach, keeping non-slip footwear on patient, and use of sitter). Adopting the specialty-specific top 10 highly effective interven- tions with staff consensus might

Huey-Ming Tzeng Chang-Yi Yin

A Multihospital Survey on Effective Interventions to Prevent Hospital

Falls in Adults

HUEY-MING TZENG, PhD, RN, FAAN, is Dean and Full Professor, College of Nursing, University of Saskatchewan, Saskatoon, Saskatchewan, Canada.

CHANG-YI YIN, MA, is Professor, Department of History, Chinese Culture University, Taipei, Taiwan.

EXECUTIVE SUMMARY Operational costs and length of stay of patients who fall in hos- pitals are greater than those who do not fall. The purpose of this study was to identify highly effective inter- ventions to prevent fall injuries as perceived by registered nurse (RN) staff for adult inpa- tients in acute hospital settings. A multihospital, cross-sectional design explored the underlying grouping structure of the nurse- perceived effectiveness items of preventive interventions in acute hospital settings. Twenty-one highly effective interventions to prevent fall injuries were identified. Ten interventions were related to improving patients’ surround- ing environment and 11 were related to increasing RN vigi- lance.

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increase staff buy-in and compli- ance. Patients’ characteristics in inpatient care units may change over time; reprioritizing effective interventions is desirable. (Tzeng & Yin, 2015). A qualitative study conducted by Shever, Titler, Mackin, and Kueny (2011) on fall prevention practices in adult med- ical-surgical inpatient care units of 51 U.S. hospitals found, as described by nurse managers, the most common interventions were using bed alarms (90%), imple- menting regular rounds (70%), using sitters (68%), and relocating patients closer to the nurses’ sta- tion (56%). About 29% of the nurse managers identified use of physical restraints as one of the interventions for fall prevention.

Previous studies (e.g., Shever et al., 2011; Spoelstra et al., 2012; Tzeng & Yin, 2013, 2015) did not explore underlying grouping struc- ture of nurse-perceived effective- ness items of preventive interven- tions in acute hospital settings. It is well known nurses have a unique body of knowledge regarding effec- tiveness of interventions to pre- vent fall injuries. However, their observations are often missing from patient charts and fall incident reports. The need is urgent to prioritize preventive interventions from RN staff per- spective about current nursing practices in acute inpatient care settings (Tzeng & Yin, 2013, 2015).

Purpose The purpose of this study was

to identify highly effective inter- ventions to prevent fall injuries as perceived by RN staff for adult inpatients in acute hospital set- tings. This work is part of a larger project. The main research question was: What are highly effective inter- ventions to prevent fall injuries as perceived by RN staff for adult inpatients in acute hospital set- tings?

A multihospital, cross-sectional design explored underlying group- ing structure of nurse-perceived effectiveness items of preventive

interventions in acute hospital set- tings. The grouping structure using an exploratory factor analysis on items in the “Effectiveness” column was developed and used to com- pute scales for items in both “Effectiveness” and “Frequency of Use” columns. Function of “mean” was used to calculate value of each scale. Authors identified the group with most highly effective interven- tions based on ranking of mean val- ues for effectiveness groups. As an exploratory study, authors also com- pared ranking of mean values for effectiveness groups with ranking of mean values for frequency-of-use groups from nurse-perceived fre- quency-of-use items using the same grouping structure.

Donabedian’s (1986) structure, process, and outcome model for healthcare organizations guided this study. Both the effectiveness of each preventive intervention and frequency of use of each pre- ventive intervention are conceptu- alized as process indicators. The outcome indicator is successful preventing injurious falls. This study focused only on the dimen- sion of the process.

Methods Design. An exploratory, cross-

sectional study was conducted at five nonprofit health systems locat- ed in the Midwest region of the United States from July 2011 through February 2012. It included 68 critical care, step-down, and noncritical acute care units for adult inpatients. Unit types includ- ed medical, surgical, combined medical-surgical, telemetry, oncol- ogy, orthopedics, cardiac, behav- ioral, women’s health/delivery, rehabilitation, and geriatric units (Tzeng & Yin, 2013). This study was approved by each health sys- tem’s institutional review board (IRB). Each IRB waived documen- tation of consent.

Sample and procedures. All participants met the following inclusion criteria: (a) 21 years of age or older, (b) employed as a staff nurse in the study unit for at least

12 months, (c) working an average of at least 20 hours per week, (d) providing direct patient care, and (e) having at least an RN license in Michigan. The exclusion criterion was working as a contingent or travel nurse. Invitations to partici- pate in the research project were placed in mailboxes of all eligible staff nurses at the study units. Participation was voluntary and anonymous. No identifiers or per- sonal information were recorded or tracked (Tzeng & Yin, 2013).

The survey package included survey tool, consent form, and an energy bar as a token gift. Survey packages were disseminated to potential participants by two trained research assistants. Parti - cipants were instructed to place completed survies in the attached envelope, seal the envelope, and drop it into the survey collection box located in the nurses’ lounge. A returned survey was interpreted as willingness and consent to participate in the study. If poten - tial participants were not willing to participate in the study, no action was required. Data were kept confidential and were used for research purposes only (Tzeng & Yin, 2013).

A total 2,170 RN staff met inclusion criteria; 560 completed the surveys (overall response rate 25.81%); all responses were includ- ed in the analyses. The response rates by health systems were: (Health System A) regional medical center with 400 beds (only one study unit, an acute rehabilitation unit, participated in this study), 7 (36.84%) of 19 RNs completed sur- veys; (Health System B) teaching medical center with 304 beds (8 study units), 92 (33.21%) of 277 RNs completed surveys; (Health System C) regional teaching med- ical center with 443 beds (12 study units), 39 (9.85%) of 396 RNs com- pleted surveys; (Health System D) regional medical center with 436 beds (13 study units), 142 (31.35%) of 453 RNs completed surveys; and (Health System E) health system with 916 beds,

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including four teaching hospitals (all four hospitals participated in this survey study, 34 study units), 280 (27.3%) of 1,025 RNs complet- ed surveys (Tzeng & Yin, 2013).

Measurement. The survey tool used in this study, The Injurious Fall Risk Factors and Fall Pre - vention Interventions Survey, was developed by the authors (Tzeng & Yin, 2013). Its development was based on previous studies and guidelines related to fall prevention (American Geriatrics Society and British Geriatrics Society Panel on Prevention of Falls in Older Persons, 2011; Currie, 2008; Gray- Miceli, 2008; Shever et al., 2011; Titler, Shever, Kanak, Picone, & Qin, 2011; Tzeng & Yin, 2008a, 2008b). Authors sought input from 11 clinical or content area experts on the initial version of the survey tool. Experts included five nurse managers, one staff nurse in acute rehabilitation, one nurse practi - tioner in mental health, one clinical pharmacist, and three master’s- prepared medical-surgi cal nursing instructors. Some wording was changed for clarity. The survey took approximately 15-40 minutes to complete; a head nurse of a surgical unit in one of the study hospitals completed the revised version of the survey tool in 15 minutes. After expert validity analysis was com- pleted, the survey tool was pretested in an adult acute rehabili - tation unit of Health System A in September 2011. Nineteen RNs met

inclusion criteria and were invited to participate in the study and seven completed the survey. No wording was changed after pre - testing. The data from this pretest are included in the analysis of this article (Tzeng & Yin, 2013).

The survey has three parts. In this present study, authors analyzed only data collected in Part II. Part I includes 81 potential risk factors that may lead to an injurious fall in adult inpatients 21 years or older. Part II includes 75 interventions for preventing injurious falls in adult inpatients (see Table 1). Parti - cipants were asked to rate these interventions using 5-point scales, based on their experience in their current unit. This part has two columns. In the “Frequency of Use” column (nurse-perceived frequen- cy-of-use items), participants rated each preventive intervention based on how often the specific interven- tion would be used to prevent injurious falls in their practice (1=rarely, 5=always). In the “Effective ness” column (nurse-per- ceived effectiveness items), partici- pants rated each preventive inter- vention based on effectiveness of the intervention in preventing inju- rious falls in their practice (1=never, 5=always). The information collect- ed using the “Effective ness” col- umn was used to answer the research question. Part III includes 12 optional items (e.g., primary working shift, the part of the fall prevention education the partici-

pant felt most helpful for prevent- ing injurious falls) (Tzeng & Yin, 2013).

Data analysis. Data were pro - cessed using SPSS 19.0 statistical software for Windows (SPSS Inc., Chicago, IL). Data from completed or partially completed surveys were included in the analysis; missing values in the partially completed surveys were kept as missing. Authors conceptualized informa- tion collected in the “Effectiveness” column captured nurses’ levels of agreement be tween their prior knowledge and their perceptions of the effectiveness of specific inter- ventions. Agreement between prior knowledge and perceptions could be established through observation and clinical experience. Because nurses’ agreement precedes their know-how (e.g., knowing how to implement fall prevention interven- tions), exploratory factor analysis was completed on the items in the “Effectiveness” column. The skew- ness and kurtosis values of effective- ness intervention items on a 5-point scale were acceptable; absolute skew- ness values for all items were less than 2.00 and absolute kurtosis val- ues were less than 2.42. Therefore, these items were treated as continu- ous variables.

The grouping structure devel- oped was used to compute the scales for items in both “Effective - ness” and “Frequency of Use” columns. The function of mean was used to calculate the value of each

Table 1. Snapshot of The Injurious Fall Risk Factors and Fall Prevention Interventions Survey

Interventions to Prevent Injurious Falls Frequency of Use Effectiveness Please rate the following items based on the nursing practice in your current unit.

1 = Rarely 2 = Occasionally 3 = Sometimes 4 = Often 5 = Always NA = Not applicable/don’t know

1 = Never effective 2 = Occasionally effective 3 = Sometimes effective 4 = Often effective 5 = Always effective NA = Not applicable/don’t know

1. Assess and modify environment as needed. 1 2 3 4 5 NA 1 2 3 4 5 NA 2. Keep floor surfaces clean and dry. 1 2 3 4 5 NA 1 2 3 4 5 NA 3. Keep non-slip, well-fitted footwear on patient. 1 2 3 4 5 NA 1 2 3 4 5 NA

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Table 2. The Five-Group Varimax-Rotated Solution from the Factor Analysis on 75 Fall Injury

Preventive Interventions

Group Item Description*

Loading of Each Item† Group 1 (23 items)

Group 2 (21 items)

Group 3 (21 items)

Group 4 (8 items)

Group 5 (2 items)

1 70. Yearly in-service requirements 0.836 0.134 0.386 0.089 -0.074 1 71. All clinical and nonclinical staff

understand the institution’s policies and procedures in place for the prevention of falls

0.836 0.225 0.216 0.182 0.026

1 57. Complete a fall risk assessment after a change in the patient’s condition.

0.828 0.218 0.199 0.240 0.257

1 56. Complete a fall risk assessment once a day.

0.816 0.236 0.176 0.218 0.265

1 69. Significant organizational support for falls reduction across departments and disciplines

0.814 0.217 0.321 0.134 0.079

1 61. Conduct a visual observation of patient’s mobility for those not confined to bed rest.

0.805 0.339 0.169 0.238 0.238

1 63. Standardized multifactorial education for staff

0.799 0.281 0.254 0.140 0.294

1 65. Standardized family education (including visual tools) and communication to families

0.797 0.298 0.312 0.157 0.132

1 62. Conduct a mental status assessment daily.

0.794 0.356 0.141 0.211 0.241

1 54. Complete a fall risk assessment at admission.

0.792 0.324 0.082 0.179 0.359

1 58. Complete a fall risk assessment after a fall.

0.787 0.279 0.174 0.174 0.307

1 73. Transparency of fall and injurious fall rates by sharing across units

0.785 0.255 0.287 0.239 -0.137

1 72. Fall prevention policies and procedures are designed for different interventions based on specific population and units

0.776 0.208 0.392 0.204 -0.135

1 64. Standardized patient education (including visual tools) and communication to patient

0.766 0.260 0.282 0.227 0.168

1 55. Complete a fall risk assessment once a shift.

0.750 0.167 0.239 0.227 0.143

1 66. A visual identification system for patient at risk of falling

0.746 0.270 0.196 0.348 0.273

1 68. Auditing of compliance with falls risk assessments and interventions

0.736 0.298 0.371 0.059 0.056

1 74. Monitor the fall rates and injurious fall rates for quality improvement purposes.

0.735 0.220 0.339 0.243 -0.116

1 67. Fall risk identification wrist band applied. 0.721 0.278 0.268 0.035 0.294 1 59. Conduct safety/post-falls debriefing. 0.721 0.342 0.300 0.029 0.161

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Table 2. (continued) The Five-Group Varimax-Rotated Solution from the Factor Analysis on 75 Fall Injury

Preventive Interventions

Group Item Description*

Loading of Each Item† Group 1 (23 items)

Group 2 (21 items)

Group 3 (21 items)

Group 4 (8 items)

Group 5 (2 items)

1 60. A fall risk assessment determined that patient has fallen in the last year.

0.715 0.347 0.338 0.125 0.110

1 75. Justify staffing levels to prevent injurious falls.

0.495 0.140 0.291 0.280 -0.167

1 31. Communication to members of the healthcare team who come in contact with patient

0.482 0.392 0.431 0.391 0.201

2 4. Reduce clutter. 0.317 0.860 0.255 0.146 0.052 2 6. Keep equipment out of patient’s pathway. 0.302 0.854 0.285 0.175 0.118 2 10. Adjust the lights for activities of daily

living. 0.309 0.850 0.269 0.172 0.125

2 1. Assess and modify environment as needed.

0.277 0.835 0.224 0.171 0.131

2 5. Reduce tripping hazards. 0.337 0.833 0.203 0.194 0.167 2 12. Minimize loud noise. 0.321 0.816 0.376 0.122 0.028 2 11. Use night light or supplemental lighting. 0.284 0.814 0.248 0.333 0.083 2 3. Keep non-slip, well-fitted footwear on

patient. 0.317 0.799 0.176 0.349 0.044

2 8. Use of patient’s regular assistive device or equipment recommended by physical therapy.

0.353 0.793 0.236 0.249 0.151

2 7. Keep patient’s personal possessions within reach.

0.323 0.791 0.296 0.246 0.175

2 9. Walker/cane available to patient 0.298 0.777 0.243 0.404 0.023 2 2. Keep floor surfaces clean and dry. 0.288 0.773 0.191 0.276 0.120 2 15. Have sturdy and unobstructed handrails. 0.251 0.634 0.445 0.066 0.436 2 16. Place patient bed in low position. 0.238 0.580 0.486 0.139 0.489 2 23. Use of a walking/transfer/gait belt during

mobility activities. 0.205 0.575 0.374 0.301 0.362

2 51. Bedrails up 0.370 0.558 0.354 0.333 0.303 2 45. One-on-one support while the patient is

in the bathroom 0.243 0.555 0.244 0.549 0.226

2 20. Bedside commode available to patient 0.276 0.543 0.475 0.325 0.291 2 18. Keep hospital bed brakes locked. 0.312 0.519 0.358 0.289 0.501 2 25. Have patient demonstrate call light use. 0.247 0.514 0.364 0.316 0.440 2 44. Relocate patient closer to nurses’ station. 0.282 0.477 0.371 0.438 0.368 3 13. Adjust temperature. 0.344 0.343 0.752 -0.086 0.119 3 17. Use special very low bed. 0.191 0.363 0.737 0.183 0.034 3 32. Referral to pharmacy 0.387 0.173 0.722 0.160 0.035 3 14. Promote pleasant ambience. 0.337 0.384 0.720 -0.108 0.205

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Table 2. (continued) The Five-Group Varimax-Rotated Solution from the Factor Analysis on 75 Fall Injury

Preventive Interventions

Group Item Description*

Loading of Each Item† Group 1 (23 items)

Group 2 (21 items)

Group 3 (21 items)

Group 4 (8 items)

Group 5 (2 items)

3 22. Apply hip protectors to prevent hip fracture.

0.320 0.246 0.708 0.208 -0.015

3 36. Strength training 0.379 0.250 0.692 0.221 0.257 3 35. Exercise 0.298 0.281 0.690 0.112 0.374 3 34. Referral to occupational therapy 0.299 0.228 0.640 0.234 0.443 3 40. Correct hearing problem. 0.314 0.290 0.633 0.293 0.306 3 21. Use of elevated toilet seats 0.214 0.510 0.632 0.271 0.116 3 39. Correct vision problem. 0.264 0.334 0.631 0.278 0.330 3 53. Avoid physical restraints. 0.397 0.281 0.619 0.314 0.186 3 50. Bedrails down 0.245 0.045 0.596 0.241 -0.051 3 28. Medication review and modification as

needed 0.387 0.225 0.581 0.453 0.078

3 29. Collaborate with physicians to identify patient’s fall risk and appropriate fall prevention plan.

0.449 0.247 0.578 0.451 -0.139

3 41. Correct dehydration problem. 0.316 0.462 0.572 0.173 0.335 3 33. Referral to physical therapy 0.378 0.335 0.568 0.202 0.364 3 37. Early and regular ambulation 0.402 0.287 0.549 0.286 0.296 3 30. Interdisciplinary collaboration on fall

prevention at the time of admission 0.493 0.295 0.547 0.442 -0.071

3 26. Instruct patient to rise slowly. 0.351 0.442 0.505 0.245 0.428 3 19. Provide supportive chairs with armrests. 0.305 0.466 0.498 0.368 0.297 4 49. Use chair exit alarm. 0.348 0.337 0.159 0.748 0.145 4 48. Use bed exit alarm. 0.361 0.343 0.134 0.713 0.126 4 47. Use of sitter 0.209 0.412 0.068 0.700 0.038 4 46. Use family assistance. 0.271 0.268 0.399 0.671 0.027 4 42. Toileting regimen (offer assistance) 0.259 0.378 0.402 0.560 0.241 4 52. Physical restraints applied 0.127 0.215 0.350 0.524 0.210 4 38. Assist transfers. 0.266 0.362 0.442 0.512 0.349 4 43. Increased observation and surveillance 0.223 0.484 0.337 0.506 0.398 5 24. Maintain call light within reach. 0.230 0.485 0.245 0.384 0.549 5 27. Reorient patient about the environment. 0.316 0.498 0.437 0.194 0.529

* Item numbers are the ones assigned in the survey tool. † The fall injury preventive intervention item with the loading in bold is grouped under the corresponding group number indicated on the first column from the top. The group number each intervention belongs to is also indicted on the far-left column.

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scale. The Cronbach alpha values and descriptive statistics (means and standard deviations) were con- ducted and results were presented in the Results section. The group with the most highly effective inter- ventions were identified based on ranking of mean values for effec- tiveness groups. Differences in ranking were compared between the effectiveness scales and corre- sponding frequency-of-use scales.

Results Demographic characteristics.

Among 560 RN participants from five health systems, 97 participants (17.3%) worked in critical units, 112 (20%) in step-down units, and 351 (62.7%) in noncritical acute care units. Forty-six (8.2%) were men, and 514 (91.8%) were women; 359 (64.1%) were younger than 45 years, 198 (35.4%) were aged 45-65, and three (0.5%) were 65 years or older. Four (0.7%) of the partici- pants were advanced nurse special- ists or nurse practitioners, and the remainder (n=554, 99.3%) were RN staff. The average tenure in the study unit when the survey was completed was 8.33 years.

The five-group solution from the factor analysis and descriptive analyses. The 75 items in nurse- perceived effectiveness items of fall injury preventive interven- tions were subjected to factor analysis (principal components analysis), which revealed presence of five groups according to scree plot and eigenvalues. The five- group solution explained 80.54% of the variance, with group 1 con- tributing 62.88% (23 items), group 2 contributing 7.33% (21 items), group 3 contributing 4.55% (21 items), group 4 contributing 3.21% (8 items), and group 5 contributing 2.57% (2 items). Table 2 shows the varimax rotated solution. All load- ings of items in each group were above 0.48.

The Cronbach alpha coeffi- cient for all 75 effectiveness items was 0.99 and the ones for the items in each effectiveness group were effectiveness group 1 (a=0.98, 23

items); effectiveness group 2 (a=0.98, 21 items); effectiveness group 3 (a=0.98, 21 items); effec- tiveness group 4 (a=0.88, 8 items); and effectiveness group 5 (a=0.84, 2 items). The same group structure was used in nurse-perceived fre- quency-of-use items of the preven- tive interventions. The Cronbach alpha coefficient for all 75 frequen- cy-of-use items was 0.97 and coef- ficients for the items in each effec- tiveness group were frequency-of- use group 1 (a=0.93, 23 items), fre- quency-of-use group 2 (a=0.94, 21 items), frequency-of-use group 3 (a=0.91, 21 items), frequency-of- use group 4 (a=0.73, 8 items), and frequency-of-use group 5 (a=0.72, 2 items).

Based on the structure of the five-group solution, function of mean was used to calculate the value of each scale for effective- ness and frequency-of-use items. A descriptive analysis by scales and rankings in the mean values with- in the five effectiveness groups and within five frequency-of-use groups is presented in Table 3 (1 as the group with highest mean value, leaning toward being highly effective or always in use, and 5 as the group with lowest mean value, leaning toward being less effective or less frequent in use). There were two rank differences between ranks of the effectiveness group 1 (ranked 4) and frequency-of-use group 1 (ranked 2), as well as between ranks of the effectiveness group 2 (ranked 1) and frequency- of-use group 2 (ranked 3). No rank difference was found between effectiveness group 3 and frequen- cy-of-use group 3 (ranked 5). There was one rank difference between ranks of the effectiveness group 4 (ranked 3) and frequency-of-use group 4 (ranked 4), as well as between ranks of the effectiveness group 5 (ranked 2) and frequency- of-use group 5 (ranked 1). In short, effectiveness group 2 (M=4.06, SD=0.57, 21 items) had the highest mean value, followed by effective- ness group 5 (M=4.04, SD=0.68, 2 items). In comparison, frequency-of-

use group 2 (M=4.085, SD=0.60, 21 items) was ranked third. Frequency- of-use group 5 (M=4.25, SD=0.72, 21 items) was ranked first.

Discussion One limitation of this study

was the limited scope of health sys- tems or hospitals and study units located in midwestern United States. Also, participation of study units and RNs was voluntary. These two limitations reduce gen- eralizability of findings to other institutions due to a potential self- selection bias. In addition, this study did not compare actual fall rates with RNs’ perceptions on effective interventions to prevent injurious falls and frequency of use of these interventions as another study limitation.

The research question was answered. Using factor analysis, a five-group solution was identified. The preventive interventions in group 2 (21 items) were highly effective. Thus, the frequency-of- use group 2 only ranked third. Interventions included in group 2 were then examined closely.

Using principles of content analysis (two authors analyzed interventions in group 2 using tech- niques of descriptive content analy- ses; differences on merged themes were discussed until a consensus was reached), interventions were differentiated into two major cate- gories as improving patients’ sur- rounding environment or increasing RN staff vigilance. As shown in Table 4, 10 of 21 highly effective interventions were related to improving patients’ surrounding environment. Among these 10 inter- ventions, two were associated with lighting, one with decreasing the noise level, three with patient room layout and design, and four with patients’ pathways. Eleven inter- ventions were related to increasing RN staff vigilance. Two of these 11 interventions were associated with increasing observation, three were patient bed-related precautions, one was offering education to patients for call light use, four

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were providing assistive devices or appropriate footwear, and one was using gait belts during mobility activities.

In summary, findings of this study agree with findings of Tzeng and Yin’s qualitative study (2008a) that most interventions to prevent falls as identified by RNs and nurse aides are related to improv- ing unsafe care environments. Some highly effective interven- tions identified in this present study are also described by nurse managers in the study conducted by Shever and associates (2011) (using sitters, relocating patients near nurses’ station, and applying physical restraints).

Conclusion Twenty-one highly effective

interventions to prevent fall injuries were identified. Ten were related to improving patients’ surrounding environment, and four of these environment modification-related interventions focused on patient pathways. Eleven were related to increasing RN staff vigilance, and four of these vigilance-related inter- ventions focused on providing assistive devices or appropriate

footwear. The 21 highly effective preventive interventions were not ranked as having the most frequent- ly used interventions in practice. This difference suggests the need to address priorities of resource allo- cation as related to making effective interventions to prevent fall injuries feasible and available to nursing staff (e.g., timely house- keeping in patient rooms, storing sufficient and free-assistive devices in the units for patient use).

Future Research For future research, additional

data collection and analysis (e.g., one-way ANOVA, multiple regres- sion analyses with binary predic- tors) is needed to explore differ- ences in RN staff perspectives on effectiveness and frequency of use of fall injury preventive interven- tions across, but not limited to, rural and urban areas, health sys- tems and hospitals, and speciali- ties and acuity levels of units (e.g., long-term care and skilled nursing home facilities). Differences in per- spectives across nursing staff and nurse managers/executives, and nursing providers and other types of providers (e.g., physicians,

physical therapists, occupational therapists, nutritionists, pharma- cists) also warrant investigation. Findings of these additional analy- ses may help nurse executives and researchers identify essential inter- ventions relevant to characteristics of settings beyond ones included in universal fall precautions. Universal fall precautions are meant to keep the patient environment safe regard- less of fall risks and hospital areas. For example, maintaining a call light within reach is one of the keys (Agency for Healthcare Research and Quality [AHRQ], 2013).

Usefulness of fall prevention on-the-job training as perceived by RN staff in content and delivery modes must also be explored as a potential predicator of RN staff perspectives on effectiveness and frequency of use of interventions to prevent fall injuries. The study conducted by Tzeng and Yin (2014) solicited RN staff percep- tions on staff education related to preventing inpatient fall injuries for adults and reported the most and least helpful approaches of staff education in the United States. Tzeng and Yin (2014) identified 19 most helpful approaches (e.g.,

Table 3. Descriptive Statistics for the Five Effectiveness Scales and the Five Frequency-of-Use Scales for the

Fall Injury Preventive Interventions for Adult Inpatients in Acute Hospital Settings (N=560)

Effectiveness Scale*

Mean (SD )

Maximum/ Minimum

Rank within the Five Effectiveness

Scales† Frequency-of- Use Scale‡

Mean (SD)

Maximum/ Minimum

Rank within the Five Frequency-of-Use

Scales† Group 1 (23 items)

3.89 (0.69)

1.00/5.00 4 Group 1 (23 items)

4.086 (0.63)

1.43/5.00 2

Group 2 (21 items)

4.06 (0.57)

1.57/5.00 1 Group 2 (21 items)

4.085 (0.60)

1.00/5.00 3

Group 3 (21 items)

3.74 (0.68)

1.00/5.00 5 Group 3 (21 items)

3.45 (0.72)

1.00/5.00 5

Group 4 (8 items)

3.96 (0.58)

1.86/5.00 3 Group 4 (8 items)

3.57 (0.69)

1.00/5.00 4

Group 5 (2 items)

4.04 (0.68)

1.00/5.00 2 Group 5 (2 items)

4.25 (0.72)

1.00/5.00 1

* Based on the 5-point scale of 1 = Never effective, 2 = Occasionally effective, 3 = Sometimes effective, 4 = Often effective, and 5 = Always effective

† The scale ranked 1 has the highest mean value and has the lowest mean value. ‡ Based on the 5-point scale of 1 = Rarely, 2 = Occasionally, 3 = Sometimes, 4 = Often, and 5 = Always

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Table 4. Categorization and Descriptive Statistics of the Intervention Items in Group 2 (21 items)

Categorization* E = Improving patients’

surrounding environment V = Increasing RN staff vigilance Item Description

Effectiveness† Mean (SD)

Frequency of Use‡ Mean (SD)

E-lighting 10. Adjust the lights for activities of daily living.

4.06 (0.69) 4.14 (0.82)

E-lighting 11. Use night light or supplemental lighting.

4.03 (0.68) 4.04 (0.90)

E-controlling the noise level 12. Minimize loud noise. 3.88 (0.78) 3.72 (0.96)

E-patient room layout and design 1. Assess and modify environment as needed.

4.08 (0.71) 4.15 (0.85)

E-patient room layout and design 7. Keep patient’s personal possessions within reach.

4.07 (0.69) 4.10 (0.78)

E-patient room layout and design 15. Have sturdy and unobstructed handrails.

4.02 (0.77) 4.15 (0.90)

E-patient pathway 4. Reduce clutter. 4.08 (0.68) 4.09 (0.81) E-patient pathway 6. Keep equipment out of patient’s

pathway. 4.10 (0.68) 4.14 (0.79)

E-patient pathway 5. Reduce tripping hazards. 4.11 (0.67) 4.17 (0.81) E-patient pathway 2. Keep floor surfaces clean and dry. 4.15 (0.67) 4.30 (0.74) V-increasing observation 45. One-on-one support while the patient

is in the bathroom 4.10 (0.69) 3.98 (0.89)

V-increasing observation 44. Relocate patient closer to nurses’ station.

3.94 (0.67) 3.75 (1.02)

V-patient bed-related precautions 16. Place patient bed in low position. 4.10 (0.75) 4.40 (0.85) V-patient bed-related precautions 51. Bedrails up 3.89 (0.75) 4.04 (0.90) V-patient bed-related precautions 18. Keep hospital bed brakes locked. 4.17 (0.74) 4.52 (0.81) V-patient education related to call light use

25. Have patient demonstrate call light use.

4.03 (0.73) 4.05 (0.99)

V-providing assistive devices or appropriate footwear

3. Keep non-slip, well-fitted footwear on patient.

4.13 (0.67) 4.31 (0.76)

V-providing assistive devices or appropriate footwear

8. Use of patient’s regular assistive device or equipment recommended by physical therapy

4.01 (0.69) 4.09 (0.85)

V-providing assistive devices or appropriate footwear

9. Walker/cane available to patient 4.01 (0.69) 3.97 (0.93)

V-providing assistive devices or providing appropriate footwear

20. Bedside commode available to patient

3.95 (0.70) 3.87 (1.03)

V-using gait belts during mobility activities 23. Use of a walking/transfer/gait belt during mobility activities

3.96 (0.72) 3.61 (1.13)

* The interventions in group 2 are labeled as E meaning “improving patients’ surrounding environment” and V meaning “increasing RN staff vigilance.” Similar interventions are given a subcategorization for illustration purposes (e.g., “E-patient pathway” as an environment-related intervention with a focus on clearing up patients’ pathway within patient rooms).

† Based on the 5-point scale of 1 = Never effective, 2 = Occasionally effective, 3 = Sometimes effective, 4 = Often effective, and 5 = Always effective ‡ Based on the 5-point scale of 1 = Rarely, 2 = Occasionally, 3 = Sometimes, 4 = Often, and 5 = Always

313NURSING ECONOMIC$/November-December 2017/Vol. 35/No. 6

applying fall risk identifiers) and 15 least helpful approaches (e.g., cer- tain assistive devices and equip- ment). Sixteen common themes of RN staff suggestions were identified for improving fall prevention edu- cation (e.g., a mandate that no high- risk patient is left alone in the bath- room with door shut).

In a study conducted by Gray- Miceli, Mazzia, and Crane (2017), 38 hospitals participated in an advanced practice nurse-led fall prevention team training, followed by coaching and mentoring over 3 months to develop inpatient care unit-based initiatives to reduce falls. Participants developed a fall risk assessment (n=29, 76.3%), staff educational intervention (n=29, 76.3%), rounding practice (n=23, 60.5%), post-fall assessment inter- vention (n=1, 55.2%), supervised toileting practice (n=11, 28.9%), responding to call lights practice (n=7, 18.4%), environmental scan- ning practice (n=6, 15.7%), staff safety awareness practice (n=6, 15.7%), or comprehensive fall pre- vention initiative (n=1, 2.6%). Gray-Miceli and associates (2017) found fall prevention team training resulted in statistically significantly decreased fall rates at 23 hospitals. The estimated mean decrease was 1.7 falls per 1,000 patient days (95% confidence limits of 0.7-2.7).

Nurse Executive Implications Hospital administrators and

unit managers should evaluate pre- ventive interventions included in fall injury reduction programs regu- larly to determine their effective- ness, as recommended by the National Quality Forum (2010), and frequency of use. One approach is to survey nursing staff and other healthcare team members using a tool similar to the one used in this present study. Also, hospital ad - ministrators and unit managers may need to adjust priorities of resource allocation about making fall injury preventive interven- tions feasible and accessible to nursing staff.

For instance, it is commonly recognized that keeping the patient environment safe should be a prior- ity regardless of fall injury risks. To acknowledge this priority, it is important for nurse managers to audit whether RNs and their assis- tants are compliant with maintain- ing a call light within patients’ reach (as one of the universal fall precautions) (AHRQ, 2013). The compliant rate of maintaining a call light within reach should be 100% or very close to it. Therefore, unit- based quality improvement initia- tives could target increasing the compliant rate and decreasing inpa- tient fall incidents due to an inabil- ity to make a call to nurses. Nurse managers and researchers could explore other opportunities that may decrease inpatient fall inci- dents due to an inability to make a call to nurses (e.g., recruiting patient safety volunteers to assist in ensuring a call light is within patients’ reach).

In closing, this study is the first to purposely identify highly effective interventions to prevent fall injuries for adult inpatients in acute hospital settings through the viewpoint of RN staff. Quality improvement projects in clinical settings are needed to validate the effectiveness of the 21 interven- tions included in group 2 to con- tinue the journey to reach zero fall injuries for adult inpatients in acute hospital settings. $

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