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Views of key stakeholders on the causes of patient falls and prevention interventions: A qualitative study using the international classification of functioning, disability and health

Veysel Karani Baris | Seyda Seren Intepeler

Nursing Faculty, Nursing Management

Department, Dokuz Eylul University, Izmir,

Turkey

Correspondence

Veysel Karani Baris, Dokuz Eylul University

Graduate School of Health Sciences, Nursing

Faculty, Nursing Management Department,

Dokuz Eylul University, Balcova, Izmir,

Turkey.

Email: [email protected];

[email protected]

Funding information

This research received no specific grant from

any funding agency in the public, commercial

or not-for-profit sectors.

Abstract

Aims and objectives: To examine the views and suggestions of healthcare profes-

sionals, patients and family members on the causes of inpatient falls and fall‐ prevention practices.

Background: Patient falls are one of the most prevalent medical errors in the hospi-

tals. In order to prevent patient falls, it is necessary to identify and classify the situa-

tions causing falls in detail and preventive interventions for these situations need to

be developed.

Design: The study was designed using a descriptive qualitative research method.

Method: The semi‐structured interviews were conducted with four physicians, four charge nurses, 12 nurses, four support staff members, eight patients and eight fam-

ily members of patients in the palliative, internal disease, surgery and orthopaedic

clinics in a training and research hospital between March 2017–May 2017. Thematic analysis method was used to analyse data. The defined themes were classified based

on the International Classification of Functioning, Disability and Health Core Set for

Falls in Acute Rehabilitation Settings.

Results: In this research, 71 themes related to situations causing falls and 30

themes related to prevention interventions were determined. Defined themes

were linked with 44 categories under five International Classification of Function-

ing, Disability and Health domains and organised accordingly. Among the cate-

gories included in the International Classification of Functioning, Disability and

Health Core Set for Falls in Acute Rehabilitation Settings, 65% were verified,

while 22 new categories that were not included in the original core set were

defined.

Conclusion: In accordance with this result, evaluating the opinions of all stakehold-

ers on the research and development of fall‐prevention programmes will increase the effectiveness of fall prevention in hospitals. The ICF model can be used to

classify the causes of falls and fall‐prevention interventions to create a common language about this topic.

Relevance to clinical practice: To prevent falls, more detailed and useful informa-

tion can be obtained by key stakeholders (all healthcare professionals, patient and

patient family). ICF Core Set For Falls can be used to systematically classify causes

of falls and fall‐prevention interventions.

Received: 21 May 2018 | Revised: 30 July 2018 | Accepted: 30 August 2018 DOI: 10.1111/jocn.14656

http://orcid.org/0000-0001-5322-4081

http://www.wileyonlinelibrary.com/journal/JOCN

K E Y W O R D S

patient falls, fall prevention, quality, patient safety, nurses, hospitals, ‘international classification of functioning, disability and health’

1 | INTRODUCTION

Patients’ falls during hospitalisation are one of the most common, but preventive medical errors, threatening the physical and mental

health of patients. It has been shown that the average number of

falls per 1,000 occupied bed days in England was 6.6 and in the Uni-

ted States of America (USA) was 3.44; and the average number of

falls per 100 occupied bed days in Japan was 3.28 (Royal College of

Physicians, 2015; Staggs, Mion, & Shorr, 2014; Hayakawa et al.,

2014). Patient falls cause fractures and serious life‐threatening inju- ries such as head and vertebra injuries which increase healthcare

requirements, lengthen the hospital stay and thereby increase

healthcare costs. Research has suggested that injurious falls in the

hospitals increase hospital costs by about $3,302.60 to $13,806

(USD) and length of stay by about 7–34 days (Baris, Intepeler, & Yeginboy, 2018; Wong et al., 2011; Zecevic et al., 2012; Dunne,

Gaboury, & Ashe, 2014).

Falls are complex event that may be affected by several factors.

The first and the most significant step in prevention of patient falls

is determining causes of falls and the associated fall‐prevention interventions (Agency for Healthcare Research and Quality—AHRQ, 2008). The most detailed and accurate information on this issue can

be provided by stakeholders associated with falls (Comer, 2016).

Therefore, this study focused on the views of key stakeholders in

falls on the causes of falls and prevention implementations. In addi-

tion, on behalf of generating an international common language,

themes associated with the causes of falls and fall‐prevention inter- ventions were classified based on the domains and categories of the

International Classification of Functioning, Disability and Health— ICF developed by the WHO that are used worldwide.

2 | BACKGROUND

To identify factors relevant to patient falls and fall‐prevention prac- tices, quantitative data such as hospital records, medical error

reports and survey results are the most used (Alamgir et al., 2015;

Hignett, Sands, & Griffiths, 2013; Tzeng & Yin, 2013). Although this

quantitative data are useful, it is limited and insufficient towards

gaining an understanding of the nature of falls. To analyse falls in a

multidimensional way, qualitative research methods should also be

used (Jagnoor, Keay, Jaswal, Kaur, & Ivers, 2013). However, there

have been only a few published studies using this method that pro-

vide rich and unique data opportunity. Previous studies mostly

examined the unidimensional stakeholder views of patients or nurses

(Dykes, Carrol, Hurley, Benoit, & Middleton, 2009; Carroll, Dykes, &

Hurley, 2010). Several stakeholders are responsible for patients’ falls (Comer, 2016). Each of these stakeholders has knowledge, aggrega-

tion and experience different from each other. Therefore, each

stakeholder can draw attention to different factors involved in the

causes of inpatient falls and each may provide different suggestions

(Vieira et al., 2011).

To generalise and implement data, a systematic classification of

data using an international common language is an important strat-

egy (Yen et al., 2014). As the causes of falls and fall‐prevention prac- tices have been classified in different ways in most published

studies, it is problematic to compare and generalise the study find-

ings; therefore, it becomes difficult to move from data into practice

(Deandrea et al., 2013; Hignett et al., 2013; Tzeng & Yin, 2013).

Studies conducted to overcome this difficulty have emphasised the

International Classification of Functioning, Disability and Health— ICF model as a detailed and reliable classification system. This sys-

tem has been suggested for use in the classification of causes of

inpatient falls and fall‐prevention practices (Huang et al., 2016; Yen et al., 2014; Vieira et al., 2011; Beninato, Portney, & Sullivan, 2009).

The ICF, developed as a classification system for assessing health

status and disability by the World Health Organization (WHO) in

2001, involved collaboration of more than 60 countries (Huang et al.,

2016). The ICF model is based on the interactions of body functions,

body structures, activities and participation, the environment and

personal factors. A practical manual published by WHO states that

the ICF can be used for a range of purposes and in various settings,

What does this paper contribute to the wider

global clinical community?

• In the context of conditions causing falls, participants mostly suggested their opinions on body functions and

environmental factors, whereas their suggestions on pre-

vention interventions were mostly related to environ-

mental factors.

• Among the stakeholder groups, the highest number of views on the causes of falls and fall-prevention interven-

tions was stated by nurses. On the other hand, there are

differences and similarities between the fall causes and

suggestions addressed by each stakeholder group.

• ICF model can be used internationally to classify the causes of falls and fall-prevention interventions.

616 | BARIS AND SEREN INTEPELER

such clinical settings, community support services, population‐based applications, education systems and policy and programme develop-

ment. In addition, it was emphasised that both quantitative and qual-

itative data can be organised with the ICF (World Health

Organization—WHO, 2013). Yen et al. (2014) developed an “ICF Core Set for Falls in Acute Rehabilitation Settings” by identifying fall risk factors and linking them to ICF categories; these authors sug-

gested using the Core Set in clinics other than acute rehabilitation

settings. Core Set is presented in Table 3. Huang et al. (2016) con-

cluded that the feasibility of application of the fall‐related “ICF Core Set for Falls in Acute Rehabilitation Settings” is high. The guideline published by AHRQ emphasised the importance of including patients

and family members in the developmental work of hospital proce-

dures (Agency for Healthcare Research and Quality (AHRQ), 2013).

However, only a few studies include healthcare providers, patients

and family members among the key stakeholders of inpatient falls. In

addition, no published study has organised the causes of falls and

fall‐prevention interventions using the ICF domains and categories. The present study will provide a comprehensive examination of the

causes of falls and fall‐prevention interventions and will guide other researchers and healthcare professionals in the studies conducted on

patient falls regarding the participation of patients and family mem-

bers besides healthcare professionals. In addition, the validity of the

ICF Core Set for Falls in Acute Rehabilitation Settings was examined

for different categories to improve the Core Set and to implement

the international use of the classification of the causes of falls and

fall‐prevention interventions as a common language.

3 | AIMS AND OBJECTIVES

To explore the views and suggestions of healthcare professionals,

patients and family members on the causes of inpatient falls and fall‐ prevention practices.

4 | METHODS

4.1 | Design

As the causes of falls and fall‐prevention interventions were exam- ined through the knowledge and experiences of the participants, the

study was conducted in the descriptive qualitative research design

(Sandelowski, 2000).

4.2 | Setting and participants

The research was conducted in the palliative care, internal disease,

surgery and orthopaedic clinics suggested the researchers by the

hospital administration of a training and research hospital in Turkey.

Participants were purposively selected using maximum variation sam-

pling (Palinkas et al., 2015) and consist of physicians, nurses, support

staffs employed in these clinics with hospitalised patients and their

family members. Charge nurses in clinical areas are more familiar

with patients and family members than researchers and have more

information about them. Therefore, the charge nurses can recom-

mend the patients and family members who are most likely to be

informed about the research topic to the researchers. Healthcare

providers with at least six‐month clinical experience and family mem- bers who agreed to participate in this study were included in the

sample. The inclusion criteria for patients were (a) able to communi-

cate effectively and (b) not having any cognitive disorder. The study

examined the general views and experiences of all participants on

situations that lead to falls and preventive interventions, even

patients who have never experienced a fall in hospital. Based on

these criteria, interviews were conducted with 40 participants: four

physicians, four charge nurses, 12 nurses, four support staffs, eight

patients and eight family members. The descriptive characteristics of

the participants are presented in Table 1.

4.3 | Data collection

The data were collected between March 2017–May 2017 through semi‐structured interviews by a researcher who had been trained in the qualitative research method. The interviews were carried out in

the meeting, seminar, treatment rooms of the clinics or in the patient

rooms due to the general well‐being of the patient. Prior to the interview, the researcher introduced himself and explained the

purpose of research and informed the participants how they would

conduct the research and that a voice recorder would be used.

The participants were asked the following questions during the

interviews: “What are the possible conditions that cause falls in this clinic?” “What can be done to prevent patient falls in this clinic?” All interviews were recorded using a digital voice recorder and tran-

scribed verbatim by the researcher. In addition, the researcher noted

the behaviour of the participants during the interviews. The inter-

view duration ranged from 10–30 minutes.

4.4 | Ethical considerations

An approval from the Non‐Interventional Clinical Research Ethics Committee of the University (Decision Date: 09.02.2017, Decision

No: 2017/02‐36) and written institutional permission from the hospi- tal where the study was conducted were obtained to conduct the

study. The aim and the method of the study were explained to the

participants, and they were also informed by a standard written

information form. Then, informed verbal and written consent was

received from all participants to ensure that the participation was

voluntary.

4.5 | Data analysis

The transcribed interview texts were analysed manually using the

thematic analysis technique (Vaismoradi, Turunen, & Bondas, 2013).

First, transcripts were read to gain an understanding of the data, and

meaning units, defined as a few of words or statements, including

the views or suggestions of the participants on the causes of falls or

BARIS AND SEREN INTEPELER | 617

fall‐prevention practices, were marked on the text. Next, short but explanatory codes were generated for each meaning unit. In the fol-

lowing step, all codes were examined in terms of their similarities

and differences, and similar codes were grouped; themes were

assigned to define each group in the best way possible. All steps of

the analysis process were independently conducted by two research-

ers educated in the process. The researchers compared their findings

after they completed the analysis and reached a consensus after dis-

cussing their differences.

4.5.1 | Linking to the ICF

To ensure common language use in the classification of causes of falls

and prevention interventions, themes that were associated with the

causes of falls by the qualitative analysis were linked with the ICF cat-

egories and organised under five ICF domains. In the case of linking,

34 categories in the ICF Core Set for Falls in Acute Rehabilitation Set-

tings were used (Yen et al., 2014). However, themes that were not

linked to any of the categories in the ICF Core Set for Falls in Acute

Rehabilitation Settings were associated with other ICF categories

(WHO, 2001). These linking processes were conducted by two

researchers through reaching consensus in each step based on ICF

definitions of WHO and previously defined ICF linking rules (Cieza et

al., 2005; World Health Organization ‐ WHO, 2001). In addition, six healthcare professionals who were knowledgeable in the ICF model

were asked for their opinions on all linking to the ICF via e‐mail, and necessary adjustments were done by evaluating their suggestions.

In this study, participants’ suggestions on fall‐prevention inter- ventions and related themes were classified based on the causal fac-

tors; some prevention interventions were linked to more than one

theme. An example of data analysis process in this research is

presented in Table 2.

4.6 | Rigour

To provide credibility, based on the peer debriefing method, an

expert in this research subject and in the area of qualitative research

was asked for his opinion on each phase of this study (Long & John-

son, 2000). In addition, as explained previously, interviews were con-

ducted with five different groups. This triangulation regarding the

data sources increased the credibility of the research (Heale & For-

bes, 2013). Both researchers conducted independent data analysis

and reached consensus on the categories and themes that increased

the dependability of the research (Anney, 2014). To ensure transfer-

ability, the sample selection and data analysis process were

explained in detail and findings were presented without any com-

ments (Shenton, 2004).

5 | RESULTS

Of the participants who were interviewed, 40% (n = 16) were

nurses, 20% (n = 8) were patients, 20% (n = 8) were family members,

10% (n = 4) were physicians and 10% (n = 4) were support staff

members. The mean age of the participants was

35.45 ± 10.95 years; 52.5% (n = 21) participants were female; and

47.5% (n = 19) were male.

After the thematic analysis, 71 themes associated with causes of

falls were defined. Based on the ICF linking rules identified by Cieza

et al. (2005), 42 of these themes were associated with 21 ICF

TABLE 1 Descriptive characteristics of participants

Characteristics

Nurse Physician Support staff Patient Family member All samples

X ± SS X ± SS X ± SS X ± SS X ± SS X ± SS

Age 33.4 ± 4.48 26.33 ± 0.94 32.5 ± 4.49 54 ± 14.67 40.85 ± 21.60 35.45 ± 10.95

n % n % n % n % n % n %

Gender

Man 1 6.25 4 100 2 50 6 75 6 75 19 47.5

Woman 15 93.75 0 0 2 50 2 25 2 25 21 52.5

Clinics

Palliative 4 25 1 25 1 25 2 25 2 25 10 25

Internal Medicine 4 25 1 25 1 25 2 25 2 25 10 25

Surgical 4 25 1 25 1 25 2 25 2 25 10 25

Orthopaedics 4 25 1 25 1 25 2 25 2 25 10 25

Total 16 40 4 10 4 10 8 20 8 20 40 100

TABLE 2 Examples of the analysis process

Meaning Unit Code Theme ICF Category ICF Domain

“Overweight patients

have

difficulty

controlling

their body

functions”

Being

Overweight

Obesity b530/Weight Maintenance

Functions

Body

Functions

“Patients use crutches

or a walker.”

Use

crutches/ walker

Use of

Walking‐ Assistant

Devices

d465/Moving

around using

equipment

Activity

and

Participation

618 | BARIS AND SEREN INTEPELER

categories (body functions = 9, body structures = 1, activity and par-

ticipation = 7 and environmental factors = 4) and one personal factor

in the ICF Core Set for Falls in Acute Rehabilitation Settings. Con-

versely, no theme was associated with 11 ICF categories (body func-

tions = 9, body structures = 1 and activity and participation = 1) and

one personal factor in the ICF Core Set for Falls in Acute Rehabilita-

tion Settings. Table 3 shows the ICF categories linked to the themes

identified in the research.

In the analysis where all ICF categories were examined, 27 of 29

themes that were not associated with any categories in the ICF Core

Set for Falls in Acute Rehabilitation Settings were associated with

20 new ICF categories (body functions = 13, body structures = 1,

activity and participation = 2 and environmental factors = 3), and the

remaining two themes were defined as two personal factors. There-

fore, new 20 ICF categories and two personal factors related with

falls that were not included in the ICF Core Set for Falls in Acute

Rehabilitation Settings were defined. Table 4 presents the new ICF

categories determined by this research.

5.1 | Causes of patient falls

In the study, 71 causes of falls were determined, 27 of which were

related to body functions, three were related to body structures, 11

were related to activity and participation, 27 were related to envi-

ronmental factors, and three were related to personal factors.

5.1.1 | Causes of patient falls associated with “body functions”

In the context of body functions, all groups specified “impaired con- sciousness” and “balance disorder” as the causes of falls, whereas “delirium,” “Alzheimer,” “dementia,” “hypotension,” “anemia,” “exhaustion/fatigue,” “diarrhea,” “often toileting” and “incontinence” were specified by only nurses, and “knee pain” was specified only by family members as causes of falls. In addition, healthcare profes-

sionals thought that “orientation disorder” and “severe pain” might cause patient falls, whereas family members and patients thought

that “lack of attention” might cause falls.

5.1.2 | Causes of patient falls associated with “body structures”

In the context of body structures, all subgroups excluding support

staff members specified that “lower extremity fractures,” nurses and physicians stated that “amputation” and family members stated that “knee diseases” might cause patient falls.

5.1.3 | Causes of patient falls associated with “activity and participation”

In the context of activity and participation, “not receiving any infor- mation from the patient,” “inattentive and wrong positioning in the bed” and “the use of walking‐assistant devices” were specified only

by nurses, whereas “taking shower by oneself” was stated by only family members as causes of falls. On the other hand, health profes-

sionals stated that “not requesting any help from family members or healthcare professionals by the patient” and patients stated that “sudden moves” and “having continuous moving in the bed” might cause patient falls.

5.1.4 | Causes of patient falls associated with “environmental factors”

In the context of environmental factors, all groups stated that “medi- cine side effects,” “multiple drug use,” “open bed rails and locks” and “lack of information, insensitivity, and unawareness of family members” might cause patient falls. In addition, nurses stated that “equipment connected to the patient (drainage, colostomy, etc.),” “clutter patient room,” “external opening of the door,” “having toilet outside of the room,” “not having an elevator” and “frequent change of family members,” whereas family members stated that “crowded service corridor” and “ineffective use of risk signs” might cause patient falls.

5.1.5 | Causes of patient falls associated with “personal factors”

In the context of personal factors, all groups stated that “age” and “lack of information, insensitivity and unawareness of patients on falls.” Only nurses and physicians stated that “the desire of men to be independent and move around” might cause falls.

5.2 | Fall‐prevention interventions

In this research, 30 themes eventually were chosen to define fall‐ prevention practices. As the participants stated identical prevention

interventions for multiple reasons during the interventions, some

themes were linked to more than one ICF category.

5.2.1 | Prevention interventions related to “body functions” and “body structures”

Regarding the body functions and body structures, all groups sug-

gested “assistive mobilization,” nurses suggested “the use of Foley catheter,” physicians suggested “regular blood glucose monitoring” and only patients and family members suggested “frequent verbal warning and informing.” All groups than other support staff members stated that “the use of walking‐assistant devices,” whereas support staff members stated that “frequent patient monitoring” could be effective to prevent patient falls.

5.2.2 | Prevention interventions related to “activity and participation”

Regarding activity and participation, all groups stated that “assistive mobilization” would be effective on preventing falls. Different than

BARIS AND SEREN INTEPELER | 619

other groups nurses suggested “early risk assessment” and “activity limitation,” whereas “effective information sharing” was suggested by support staff members other than nurses.

5.2.3 | Prevention interventions related to “environmental factors”

Regarding environmental factors, all groups thought that “informing family members and including them in the care process” would be effective to prevent falls, whereas “having toilet and bath in each room” was suggested by all groups except physicians. In addition, “informing patients on medicine,” “the use of bed alarms” and “hav- ing regular rooms” were stated by only nurses as fall‐prevention interventions, “sufficient number transferring products (stretcher, wheeled chair, etc.)” and “organizing the cleaning hour” were stated only by patients, and “handrails in the toilets” were stated only by physicians as fall‐prevention interventions. Also, nurses and family members stated that “assessing the medicines in terms of risk of fall- ing,” “a more effective and clear risk sign” and “the inclusion of edu- cated healthcare professionals rather than family members” would be effective to prevent patient falls, whereas patients stated that

“an increase in the number of healthcare professionals” would be effective to prevent falls.

5.2.4 | Prevention interventions related to “personal factors”

Regarding personal factors, all groups suggested “the use of walking‐ assistant devices” and “educating patients by visual (video etc.) methods,” whereas nurses, physicians and family members also sta- ted “warning posters.”

In the context of research, 101 themes related with the causes

of falls and fall‐prevention interventions, 44 categories which were associated with themes under five ICF domains; 83 quotes are speci-

fied in Table 5.

6 | DISCUSSION

In this research, in addition to the views of healthcare professionals

on the causes of patient falls and fall‐prevention practices, the views of patients who were at the centre of falls and the views of their

family members who accompany with them were also included in

the study. The guideline published by the Agency for Healthcare

Research and Quality (AHRQ) remarked the importance of the inclu-

sion of patients and family members along with the healthcare pro-

fessionals for the procedure development studies in hospitals

(AHRQ, 2013). Examined the views of the participants, it was deter-

mined that nurses were those who expressed the highest number of

opinions on the causes of falls and fall‐prevention practices among the groups, whereas support staff members expressed the fewest

opinions. Nurses’ professional education, knowledge or clinical expe- rience, and close interactions with their patients might have madeT

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620 | BARIS AND SEREN INTEPELER

them more knowledgeable and experienced on patient falls; there-

fore, they might have presented more opinions than others (Kirk-

patrick, Boblin, Ireland, & Robertson, 2014). Regarding providing

care, support staff members take responsibility only for patient

transfers, and apart from that, they only interact with patients for

routine cleaning of patient rooms and clinics. They might have

expressed fewer opinions compared to other groups as they have

fewer interactions with patients. But support staffs are key stake-

holders and should be encouraged to speak up about what they see.

Nurses expressed the most opinions about the causes of falls in the

five ICF domains, and opinions about body functions and environ-

mental factors were stated the most—except the nurses—by the family members and the patients, respectively. In addition, patients

and family members expressed more opinions than physicians; they

also stated several causes of patient falls and fall‐prevention inter- ventions (e.g., ineffective use of risk signs and organising regular

cleaning hours) that were not addressed by healthcare professionals.

This result supported the view that patients and family members are

among key stakeholders in patient fall prevention, and their partici-

pation in the research and practices regarding falls is important.

In this research, data on 11 ICF categories and one personal

factor included in the ICF‐CSFARS could not be reached. Similarly, Huang et al. (2016) could not acquire data on some of the ICF cat-

egories in their feasibility study on the ICF Core Set for Falls in

Acute Rehabilitation Settings. This may result from differences in

research designs, data properties and study populations. However,

the present research verified 21 ICF categories and one personal

factor in the ICF‐CSFARS and 20 new ICF categories and two per- sonal factors related to patient falls were defined as different from

those in the Core Set. The research had a qualitative design: Its

sample consisted of key stakeholders associated with patient falls

and the research conducted in different internal and surgical clinics,

all of which was useful for obtaining richer data (Jagnoor et al.,

2013). In this direction, 20 ICF categories and two personal factors

defined in this research were added to the ICF Core Set for Falls in

Acute Rehabilitation Settings, which was extended as the “ICF Core

Set for Falls” that can be used to classify all causes of falls and fall‐ prevention interventions for all hospital departments and patients.

Considered the opinions of all participants, their views on causes

of falls were mostly related to body functions and environmental fac-

tors, whereas their suggestions on prevention interventions were

mostly related with environmental factors. The least number of opin-

ions was expressed in the domain of body structures. In this research,

participants stated causes of falls similar to those found in the litera-

ture, such as mental disorder (Tzeng & Yin, 2013), postural hypoten-

sion (Enderlin et al., 2015), hypoglycaemia (Gu, Balcaen, Ni, Ampe, &

Goffin, 2016), walking by oneself (Hignett et al., 2013), multiple use of

medicine (Tripathy, Jagnoor, Patro, Dhillon, & Kumar, 2015), slippery/

wet ground (Gu et al., 2016), nursing shortage (Cox et al., 2015) and

age (Zecevic, Salmoni, Speechley, & Vandervoort, 2006). However,

there have been a few studies stating that radiotherapy treatment

causes patient falls (Allan‐Gibbs, 2010). In addition, in the present study, although falls were associated with the sex of the participants,

this is different from published literature where was stated that being

male increases the falling risk (Kwan, Close, Wong, & Lord, 2011;

Deandrea et al., 2013). The published studies focused on the gender‐ based physiological differences, whereas in this study, participants

associated the patient falls with the desire of men to be more indepen-

dent and move around. However, this difference may be due to the

small sample size of research.

Most fall‐prevention practices stated by the participants showed similarities with the literature: frequent patient monitoring (Tzeng &

Yin, 2013), review of medicines in terms of falling risks of the

patients (Miake‐Lye, Hempel, Ganz, & Shekelle, 2013), assistive mobilisation (AHRQ, 2012), educating healthcare professionals (Stern

and Jayasekara, 2009) or having the bath and toilet inside the

patient room (Tzeng & Yin, 2008). However, in the present research,

the participants suggested using a Foley catheter to protect the

patients with incontinence from falls, whereas the literature sug-

gested helping patients meet their toilet needs by asking their needs

in frequent and regular visits and suggested the use of a bedpan for

patients who should not get out the bed (Agency for Healthcare

TABLE 4 The new ICF categories associated with falls

Body functions Body structures Activities and participation Environmental factors Personal factors

ICF Code/ICF Category Title

b117/Intellectual functions b147/Psychomotor functions b2401/Dizziness b280/Sensation of pain b28016/Pain in joints b4202/Maintenance of blood pressure b4300/Production of blood b455/Exercise tolerance functions b530/Weight maintenance functions b540/General metabolic functions b5450/Water balance b6201/Frequency of urination b6202/Urinary continence

s75011/Knee joint d310/ Communication

with—receiving —spoken messages

d510/Washing oneself

e115/Products and technology for personal use

in daily living

e315/Extended Family e340/Personal Care Providers and Personal

Assistants

e355/Health Professionals

Gender

Lack of knowledge

BARIS AND SEREN INTEPELER | 621

TABLE 5 Associated research themes about conditions causing falls, fall‐prevention practices and quotes which were classified according to the ICF domains and categories

ICF No/ICF category

Associated research themes about conditions causing fall

Associated research themes about fall prevention Quotes

ICF DOMAIN: Body Functions

b110/Mental Functions Impaired consciousness (Pt) (Fm) (Ph) (N) (S)

Assistive mobilisation (N)

(Ph) (Pt) (Fm) (S)

“For instance, patients think that they lie on their own beds at home, they think that they can get up from their beds

and walk.” (Fm) “For example, there are a lot of Alzheimer patients, it is very difficult for us to manage them. Because

they cannot perceive ongoing things, they certainly cannot

think about the outcomes, they can have instant moves…” (N) “…Well, patients who had received a blow on their heads have an orientation disorder. We prefer to not to

rout them out of their beds (in terms of falling risk).” (N)”Patients with impaired consciousness should not move alone, family members should help them.” (N) “Although they are not bedridden, the patients who have weak

cognitive functions with high Alzheimer and dementia risks

take self‐rides at nights, which is a fundamental problem for us.” (N)

Mental disorder (Pt)

(Fm) (N) (S)

Delirium (N)

b114/Orientation Functions

Orientation disorder

(Ph) (N)

Alzheimer (N)

Unable to orient to the

hospital or the clinic

(Fm) (Pt) (N)

b117/Intellectual Functionsa

Dementia (N)

b140/Attention Functions

Patient's lack of attention (Pt) (Fm)

Frequent verbal warning

and informing (Fm) (Pt)

“…most of them (falls) may result from our own inattentiveness.” (Pt) “There may be seen some falls due to the patient's lack of attention.” (Fm) “…They (patients) should always be warned.”(Fm)

b147/Psychomotor Functionsa

Agitated patient (Fm)

(Ph) (N) (S)

Frequent patient

monitoring (Fm) (N) (S)

“…Agitated patients may throw themselves around…” (S) “To prevent these (falls)…patients should be continuously monitored…” (Fm)

b210/Seeing Function Visual impairment (Pt) (Fm) (N)

Assistive mobilisation (N)

(Ph) (Pt) (Fm) (S)

Using Handrails (N)

(Fm) (Ph) (Pt)

Frequent monitoring of

vital signs (N) (Fm) (Ph)

“Patients with visual impairment naturally fall, because they cannot see their directions….” (Pt) “… My patient staggers while walking; he should hold the handrails at the

corridor.” (Fm) “…For instance, on the day of my first hospitalization, while I was walking up, I felt dizzy. Let me

put in this way, if they blow from one kilometer away, I

would feel about to fall.” (Pt) “Patients lean out to right or left due to their pains.” (S) “Patients who have too severe pain may fall.” (N) “… Patients may fall due to the knee pain.” (Fm) “…There should be someone near the patient while they were walking.” (Fm) “Blood pressure, dizziness, patients can fall for these reasons. Blood pressure may increase or decrease in a very

dangerous way…” (Pt)

b235/Vestibular Functions

Balance disorders (Pt)

(Fm) (Ph) (N) (S)

b2401/Dizzinessa Dizziness (Pt) (Fm) (Ph) (N) (S)

b280/Sensation of Paina Severe pain (Ph) (N) (S)

b28016/Pain in Jointsa Knee pain (Fm)

b4201/Decreased Blood Pressure

Hypotension (N)

b4202/Maintenance of Blood Pressurea

Postural hypotension

(Fm) (Ph) (N)

Frequent monitoring of

vital signs (N) (Fm) (Ph)

Warning posters or

brochures (Fm) (Ph) (N)

“…For instance, patients may fall due to the postural hypotension that occurs when a patient's blood pressure falls when suddenly standing up from a lying or sitting

position.” (Ph) “… Patients’ blood pressures could be continuously monitored…” (Fm) “…A written warning may be hand on the walls ‘patients who lie down for long time, please do not directly walk after suddenly stand up from a

lying position, please sit for 2‐3 minutes…” (Fm) “There may be seen dizziness, or falls due to the anemia.” (N)

b4300/Production of Blooda

Anaemia (N)

b455/Exercise Tolerance Functionsa

Exhaustion/Fatigue (N) Assistive mobilisation (N) (Ph) (Pt) (Fm) (S)

“They are mostly unable to provide their own body movements due to their exhaustion or fatigue. Therefore,

family members should assist them as good as they can.” (N)

“Overweight patients have difficulty to control their bodies… When they do something, there is an increase in their potential of falling” (Ph) “It is somehow dangerous to carry overweight patients, as our muscle power may not be sufficient to carry them…” (S)

b530/Weight Maintenance Functionsa

Obesity (Pt) (Fm) (Ph)

(S)

(Continues)

622 | BARIS AND SEREN INTEPELER

TABLE 5 (Continued)

ICF No/ICF category

Associated research themes about conditions causing fall

Associated research themes about fall prevention Quotes

b540/General Metabolic Functionsa

Hypoglycaemia (Pt) (Fm)

(Ph) (N)

Regular blood glucose

monitoring (Ph)

“…It may be hypoglycemia, because we follow these patients when they are hungry—for instance we may follow patients for 72 hours while they are hungry …” (Ph) “…Diabetic patients may fall because of hypoglycemia.” (N) “…Patients’ blood glucose levels should be monitored…” (Ph)

b5450/Water Balancea Dehydration (Ph) (N) “…After an enema, most of the patients lose their balance at the toilet and fall …” (N)Diarrhoea (N)

b6201/Frequency of Urinationa

Often toileting (N) The use of Foley

catheter (N)

“…Patients go to the toilet very often. Going to the toilet is an important issue for me as they fall when they stand up

to go to the toilet. A Foley catheter may be used to

prevent this problem…” (N)“…Patients with incontinence particularly have the phobia of leakage, may hurry up to

arrive the toilet.” (N)

b6202/Urinary Continencea

Incontinence (N)

b730/Muscle Power Functions

Muscle weakness (Pt)

(Fm) (Ph) (S)

The use of walking‐ assistive devices (Ph)

(Fm) (N) (Pt)

Assistive mobilisation

(N) (Ph) (Pt) (Fm) (S)

“Most of them (falls)… may due to weakness.” (Pt) “Patients may use walking‐assistive devices while they are walking.” (Fm) “There can be some moments in which the patient is unable to keep their balance. There may be falls for this

reason.” (N) “…The patient staggers, it is dangerous to leave him alone…” (Fm) Patients who have difficulties to walk, may walk using walkers…For instance, some patients can be provided with personal adjustable

walkers… (N)

b755/Involuntary Movement Reaction

Functions

Balance disorder (Pt)

(Fm) (Ph) (N) (S)

b770/Gait Pattern Functions

Gait disturbance (Pt)

(Fm) (Ph) (N)

ICF DOMAIN: Body Structures

s750 Structures of the

Lower Extremity

Lower extremity

fractures (Pt) (Fm) (Ph)

(N)

The use of walking‐ assistive devices (Ph)

(Fm) (N) (Pt)

“…fractures or injuries on the legs…amputated legs…” (Ph) … “For instance, patients may have knee disease, so they are prone to falling” (Fm) “…If patients have walkers they never fall.” (Pt)Amputation (N) (Ph)

s75011/Knee Jointa Knee diseases (Fm)

ICF DOMAIN: Activity and Participation

d310/Communicating with—Receiving— Spoken Messagesa

Patients do not request

any help from family

members and

healthcare professionals

(Ph) (N) (S)

Early risk assessment (N)

Sharing effective

information (S) (N)

“Particularly the elderly do not want to wake their family members. There may be their grandson or granddaughter,

and they do not want to wake them and do go to

toilet alone.” (N) “Patients can hide their past information while giving their medical history, then we

learn the medicines they take in case of any fall related

issue.” (N) “We should assess and determine the risk as earliest as possible and inform other healthcare

professionals or the support staff members,

physicians, and family members

accordingly.” (N)

Not receiving any

information from the

patient (N)

d410/Changing Basic Body Position

Sudden move (Pt) (N) Frequent patient

monitoring (Fm) (N) (S)

“Sudden stands and sudden moves of the patients…may cause falls.” (Fm) “During their care, in the course of their hourly position change, some patients may fall from the bed while they

are moved in their bed.” (N) “In any case, while sleeping, patients turn right, or turn left…” (S) “A majority of patients with falling risk are bedridden

patients. We should check their in‐bed positions.” (N) “Also, we should monitor patients often…” (N)

d415/Maintaining a body position

Continuous moving in

the bed (Pt) (N) (S)

Giving an inattentive

and wrong position in

the bed (N)

(Continues)

BARIS AND SEREN INTEPELER | 623

TABLE 5 (Continued)

ICF No/ICF category

Associated research themes about conditions causing fall

Associated research themes about fall prevention Quotes

d450/Walking Walking alone (Pt) (Fm) (Ph) (N)

Assistive mobilisation (N)

(Ph) (Pt) (Fm) (S)

Activity limitation (N)

“For instance, patients wake up and walk alone at night…” (N) “If you walk with another person, you watch around using four eyes, if you miss something the other person

sees it.” (Pt) “I see that patients climb up and down the stairs, which is very dangerous…” (Fm) “We have stairs in the hospital, as patients make an effort while they climb

up and down the stairs…we have experienced falling down from the stairs for a couple of cases.” (N) “… patients may use crutches, or walker…” (N) “Patients cannot lean down at the bathroom, they cannot do

anything…You should not let them be alone….” (Pt) “… patients particularly want to go to the toilet alone…Once, I have experienced such a thing…The patient slipped and fell in the toilet although his family member was waiting at

the door” (N) “…If a patient has a high falling risk, his activity should be more limited …” (N)

d455/Moving Around Climbing stairs (Fm) (S) (N)

d460/Moving Around in Different Locations

Moving around by

oneself (going out to

the hospital garden,

etc.) (N) (Fm)

d465/Moving Around using Equipment

The use of walking‐ assistant devices (N)

d510/Washing Oneselfa Taking shower by oneself (Fm)

d530/Toileting Going to toilet by oneself (Fm) (N)

ICF DOMAIN: Environmental Factors

e1101/Drugs Medicine side effect (Fm) (Ph) (N) (S) (Pt)

Assessment of Medicines

in term of falling risk

(Fm) (N)

Informing patients on

the use of medicines

(N)

“There are a wide range of medicines, some of them make people better while some of them make it dizzy…” (Fm) “In other words, medicines can be assessed by an expert and his team.” (Fm) “Risky medicines are used here, their side effects can be explained to the patient.” (N)

The use of multiple

medicines (Fm) (Ph) (N)

(S) (Pt)

The use of radiotherapy

—anaesthesia (N) (Fm) (Pt)

e115/Products or Substances for Personal

Consumptiona

The selection of

improper clothing,

shoes (Pt) (Fm) (N)

Proper clothes and shoes

(N) (Pt) (Fm)

“…they can try to walk with flip flops while they wear socks… or they can wear high heel shoes, or they don't wear the shoes completely. All of these are risky.” (N) “… Our slippers are not proper to walk on these tiles as they

slipped after a wrong step.” (Pt) “…If they walk as connected to the medical devices, there can be falls

associated with these devices, at least two medical

devices.” (N)

The use of multiple

equipment (Pt) (N)

The equipment

connected to the

patient (drainage,

colostomy) (N)

e120/Products and Technologies for

Personal Indoor and

Outdoor Mobility and

Transportation

Problems with beds and

stretchers (N) (S)

Sufficient number of

transferring products

(stretcher, wheeled

chair, etc.) (Pt)

Qualified beds meeting

the standards (N) (S)

The use of bed alarm

system (N)

“The length of the beds should be arranged. Some of our patients use one step stair…The patient may slip when he was on the step and fall.” (N) “Bed rails are not safe.” (N) “…For instance, there are two or three wheeled chairs, everyone waits his turn. Or those of who don't wait the line, arm‐in‐arm walk with someone… It would be better if there are more wheeled chair in the hospital.” (Pt) “I've heard that there are specially designed beds that signal

when the patient gets up from the bed. There is no such

thing in our hospital” (N) “If there would be such special things in the beds, we would install this, it would signal

when the patient gets up from the bed, and if I would

know that the patient gets out of his bed …” (N)

Open bed rails and

locks (Ph) (Fm) (N) (S)

(Pt)

A low number of

walking‐assistive devices (Fm) (N)

e150/Design, Construction and

Building Products and

Technology of Buildings

for Public Use

Slippery/wet ground (Pt) (N)

Organising regular

cleaning hours (Pt)

Handrails in the toilets

(Ph)

Providing regular

patient rooms (N)

A more effective and

understandable fall risk

sign (N) (Fm)

“…for instance, the cleaning hours may be…defined as the time when there is nobody walking around.” (Pt) “You go to toilet, for instance there is no handrail in it.” (Pt) “Clinics should have fewer furniture which should be situated away from the patient.” (N) “For instance…there is a sign of a four‐leaf clover (fall‐risk sign), but patients do not know what it means. Actually, what it means can be

written under the sign…” (Fm) “Well, a four‐leaf clover (fall risk sign) does not mean anything for everyone. Even,

Door stoppers (Pt) (Fm)

(S)

High inclined stairs (Pt)

(Ph)

(Continues)

624 | BARIS AND SEREN INTEPELER

TABLE 5 (Continued)

ICF No/ICF category

Associated research themes about conditions causing fall

Associated research themes about fall prevention Quotes

what is the connection of a four‐leaf clover with fall…But, if that sign can be re‐designed to indicate fall, there may not need to remind the patients accordingly.” (N)

Not having any

handrails at the

corridor (Pt) (N)

Irregular patient room

(N)

The fall risk sign is not

understood (Fm) (N)

e150/Design, Construction and

Building Products and

Technology of Buildings

for Public Use

(continued)

External opening of the

room door (N)

Toilet and bath for each

room (Pt) (Fm) (N) (S)

Non‐slip surfaces in bathrooms (Pt) (N)

An effective lighting

system (Ph) (N)

“There is no toilet and bath in each patient room here, which is one of the triggering risk factors…Therefore, there is a long distance, and patients have to walk more

than 10 m, which increases the risk. When they walk 1

meter more, the risk also increases by 1 meter.” (N) “It is important to have a toilet inside the room as the patient

wants to go toilet by walking the whole distance” (N) “…It is proper to use crinkled surfaces in the design of hospital

bathrooms.” (N) “For instance, there is only one light in the corridor, when you close the light, it becomes utter darkness. Spot lambs

which will automatically open while patients walk through

the corridor…” (N)

Having toilet outside of

the room (N)

Not having an elevator

(N)

Crowded service

corridor (Fm)

Ineffective use of risk

signs (Fm)

e240/Light Insufficient lighting (Ph) (N)

e315/Extended Familya Lack of information, insensitivity and

unawareness of family

members (Pt) (Fm) (N)

(Ph) (S)

Informing family

members and including

them in the care

process (Pt) (Fm) (Ph)

(N) (S)

Having healthcare

professionals instead of

family members (N)

(Fm)

“For instance, family members might have low education status, they may be the elderly, the companions do not

convey information to each other.” (Fm) “…On the other hand, as I said before, nurses or doctors may be

knowledgeable on this issue, they know everything in a

detailed way, but when they do not share their knowledge

with us or when we do not know them, they experience a

lot of problems. Because family members stay with the

patient for a whole 24‐hr period, but doctors sometimes visit the patients, give their medicines, but family members

are the ones who need the know more information.” (Fm) “Well, I think there is no need any family members to stay near the hospitalized patient. The patient stays in the

clinic, all of his demands are met by the hospital, for

instance monitoring his falls, eating, etc. will be done by

well‐experienced staffs, I think if everyone knows his own responsibilities, the numbers of patient falls will decrease.” (N)

Not having any family

members (Fm) (Ph) (N)

(S)

Frequent changes of

family members (N)

e340/Personal Care Providers and Personal

Assistantsa

Lack of information,

insensitivity and

unawareness of

healthcare providers

(Pt) (N) (Ph)

e355/Health Professionalsa

Lack of information,

insensitivity and

unawareness of

healthcare providers (N)

(Pt) (Ph)

Education of healthcare

professionals (N) (Ph)

Increase the number of

healthcare professionals

(N) (S) (Pt)

“As I see it, patient falls are mainly based on the actions of healthcare professionals.” (N) “…if an education is provided for healthcare professionals such that doctors

and nurses, and everyone would be conscious for patient

falls everything would be better.” (N) “If I manage fewer patients, I can have more effective interventions and care

more with these patients. But, there are only two

personnel during the weekday shifts, our service has a

capacity of 24 patients, but we have 24 hr shifts and we

are only two people. Of course, it is getting difficult to

control the clinic or there is an increase in the fatigue

level. You can easily miss something, or you could be

exhausted as you are tired, which may also be the reason

for that…” (N)

Low number of nurses

(Pt) (Fm) (N)

(Continues)

BARIS AND SEREN INTEPELER | 625

Research and Quality (AHRQ), 2012). Considering the infection risk

of the Foley catheter, it may be assumed that the use of a bedpan

will be more effective for the patient safety, as suggested in the lit-

erature (Chenoweth & Saint, 2011). Participants in that study stated

that the use of proper shoes, slippers and proper clothes would be

effective for preventing falls. The literature stated that the use of

proper shoes and slippers is effective to prevent falls (Tzeng and Yin

(2013) while nothing was concluded about wearing proper clothes.

However, patients who wear wide, long clothes with some apparatus

on them such that belts and in particular those who have an atten-

tion disorder or impaired consciousness may fall by stumbling on

something, as they cannot watch all around themselves. In this study,

the fall‐risk sign was confirmed as an effective fall‐prevention inter- vention by the participants, but it was also insisted that the four‐leaf clover sign that the Ministry of Health of the Republic of Turkey rec-

ommended being used by the nurses was not effective and under-

standable. Participants stated that a more understandable fall risk sign

would be effective for preventing patient falls. Like this study, pub-

lished studies determined that indicating the higher falling risk of

patients using the fall risk sign actually was a prevention intervention

(Hempel et al., 2013; Agency for Healthcare Research and Quality

(AHRQ), 2012). However, there were few studies that noted the

importance of the understandability of the fall risk icons (Hurley,

Dykes, Carrol, Dykes, & Middleton, 2009). Thanks to the risk for falls

sign, healthcare professionals, patients and family members are

informed about the patients who have high risk of falls. Therefore,

the use of fall risk sign to indicate the falling risk in an understandable

way that may be assumed to be effective in preventing patient falls

through increasing communication of an observed falling risk.

7 | LIMITATIONS

Healthcare workers such as physiotherapists, pharmacists and dieti-

tians who were not actively working in the clinics where the

research was conducted could not be included in the sample. That

these persons are also key stakeholders in responses to patient falls,

asking for the opinions of other healthcare professionals may pro-

vide richer data. In addition, this research was conducted only in

two internal medicine and two surgical clinics. As this research was

not carried out in all clinics in the hospital, the number of the sam-

ples was limited. The research may provide limited information

regarding various experiences and suggestions for the causes of falls

and fall‐prevention interventions. Although patients participating in the study have never experienced a fall in hospital, they expressed

their general views on the fall. This may have caused a limitation to

the details and original information about falls.

8 | CONCLUSION

Examining the opinions of participants, the causes of falls were mostly

related to body functions and environmental factors; each group of par-

ticipants drew attention to common causes of falls and fall‐prevention

TABLE 5 (Continued)

ICF No/ICF category

Associated research themes about conditions causing fall

Associated research themes about fall prevention Quotes

Personal Factors

Age Age (Pt) (Fm) (Ph) (N) (S) The use of walking‐ assistant devices (Ph)

(Fm) (N) (Pt) (S)

Educating the patients

using the visual

methods (video, etc.)

(H) (Fm) (Ph) (N) (S)

Warning brochures (Fm)

(Ph) (N)

“Age is an important factor, as people get older, their body functions would decline… the possibility of falling increases.” (Ph) “Elderly patients definitely fall, well, I think what we should do for them…for instance, there are walkers, or some assistive devices…” (N) “If we consider gender‐based factors, we might have the desire of men to be more independent and move around… In case men have some power, they have a tendency to

stand, or go out.” (Ph) “…although you take necessary measures, patients may want to go to the toilet by oneself without any

companions or without receiving any help. The patient

might not be conscious of the risks of going to

toilet alone?” (Pt) “…(related with falls) some animations, or videos can be watched… I think those will be more effective as each patient room has a computer and a television. This kind of

15 min videos may be watched in the morning, during the

noon, in the evening, and at night.” (N) “Well, warning brochures may be hanged on each room, such as: here is the risk factors.” (Fm)

Sexa The desire of men to

be independent and

move around (Ph) (N)

Lack of Informationa Lack of information,

insensitivity and

unawareness of

patients (Pt) (Fm) (N)

(Ph) (S)

aA new ICF Category that was not included in the original ICF Core Set for Falls in Acute Rehabilitation Settings but was defined in the context of this

research.

N: nurse, Ph: physician, S: support staff, Pt: patient, Fm: family member.

626 | BARIS AND SEREN INTEPELER

interventions as well as different causes of falls and prevention interven-

tions. These research findings suggested that the participation of all

stakeholders in the further studies of patient falls will provide a more

detailed analysis of this topic. In addition, asking patients and family

members for their opinions on the practical development of fall‐preven- tion programmes and their developmental process will lead more com-

prehensive and effective fall‐prevention programmes. Additionally, a systematic and detailed classification of the causes of falls will be useful

to define the prioritised areas of the prevention programmes.

The internationally valid ICF model classifies the data in a

detailed and systematic way that could be used to generate a com-

mon language for the classification of the causes of falls and fall‐pre- vention interventions. In this research, 65% of categories in the ICF

Core Set for Falls in Acute Rehabilitation Settings were verified

using this study sample. In addition, 20 ICF and two personal factor

categories that had not been included in the Core Set were defined.

Based on this result, 22 categories defined in the present research

may be added to the ICF Core Set for Falls in Acute Rehabilitation

Settings to extend it as the ICF Core Set for Falls. Further research

may carry out validity and feasibility studies of the ICF Core Set for

Falls in different clinics and hospitals. In addition, the ICF model can

also be used in future research to classify the causes of other medi-

cal errors such as pressure ulcers and medication errors.

9 | RELEVANCE TO CLINICAL PRACTICE

Patient falls are an important international patient safety problem:

They threaten the physical and mental health of the patients and

waste nations’ economic resources. Clinical managers should ask for the opinions of all stakeholders related to patient falls to implement

an effective and comprehensive prevention programme and to pro-

mote their participation in those practices. Primarily focusing areas

to prevent patient falls may be determined through the systematic

classification of the causes of falls and prevention interventions by

using the ICF model.

ACKNOWLEDGEMENTS

We would like to thank all participants who shared their views in

this study and all healthcare professionals for their opinions on ICF

linking. We are also grateful to all the hospital administrators for

their support in conducting the research.

CONFLICT OF INTEREST

No conflict of interest has been declared by the authors.

AUTHOR CONTRIBUTIONS

Study Design: Veysel Karani Baris, Seyda Seren Intepeler; Data col-

lection and analysis: Veysel Karani Baris, Seyda Seren Intepeler;

Manuscript preparation: Veysel Karani Baris, Seyda Seren Intepeler.

ORCID

Veysel Karani Baris http://orcid.org/0000-0001-5322-4081

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