Running Head: RESEARCH PROPOSAL PT 2
Research Proposal Part 2
NURS 500
Liberty University
Spring 2019
Abstract
RESEARCH PROPOSAL PT 2 2
Reducing the incidence of falls is a National Patient Safety Goal and yet falls in places providing
health care are still quite frequent. According to the Center for Disease Control injuries related to
falls in a healthcare setting cost more than 30 billion dollars per year. Of that more than 30
billion dollars per year, 66% is in hospital costs alone. The frequency of falls and the costs
associated with them have led researchers to investigate what intrinsic and/or extrinsic factors
play a role and also what specifically can be altered or changed to reduce the number of falls.
The vast majority of falls are not witnessed by healthcare staff and so the research relies heavily
on the documentation of intrinsic variables. However, this often leads to various extrinsic or
environmental variables from being considered or factored in. In this paper two separate research
studies will be discussed that specifically factored in environmental variables such as hospital
layout and design and how those variable impacted and contributed to the frequency of falls.
Research Proposal: Part 2
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First Research Study
The first study from the literature was a joint study by the Center for Health Design along
with the Coalition of Health Environments. Both of these organizations approached the research
with the intent of examining all possible factors since falls are often the result of different
variables sometimes even combined variables (Pati, Lee, Mihandoust, Kazem-Zadeh, and Oh,
2018).
The researchers analyzed the risk of falling by examining the specific factors related to
the behavior associated with the fall, the intrinsic variables of the individual, and the extrinsic
variables of the environment. They also looked at the connection between those intrinsic and
extrinsic variables and if they interacted and if that interaction helped contribute to a fall. They
were especially interested in the environmental variables. These were things such as light or lack
of light in the room, the type of floor in the room, what sort of shoes if any a patient was
wearing, as well as the actual physical design of the room itself. They determined ahead of time
that actual structural changes would be challenging to research because of the considerable costs
associated with doing so. However, non structural modifications to the layout and design of the
room were considered in the study. These included such things as the location of furniture and
accessories, if the room had any handrails and where they were located, and what type of surface
was used for the floor of the room. It was determined that these types of factors can be changed
with little difficulty if they adversely affect the safety of the room. One of the conclusions of the
study was that any furniture must be placed in such a way as to never prevent clear and
unobstructed movement in the room between the bed and the door to the room and the door to
the bathroom (Pati, Lee, Mihandoust, Kazem-Zadeh, and Oh, 2018).
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The actually floor material did not seem to lead to an increased risk, but there were still
consideration regarding the flooring. It was discovered that the way a floor is cleaned or what
products are used to clean it can cause it to become slick or slippery, especially to certain foot
ware. This was not common, but was mentioned by the researchers. The study also found that
while there is ample evidence that lack of home based handrails is a contributing factor in falls in
the home, there was no link that their presence or lack thereof was a variable in a healthcare
setting where falls are concerned.
The researchers took the study one step further than previous studies by also examining
the individual traits of the environment. They desired, if possible, to connect specific elements of
the environment with increases or decreases in fall incidence (Pati, Lee, Mihandoust, Kazem-
Zadeh, and Oh, 2018). To do this they analyzed more than forty characteristics of a hospital
room. What they found was that an overwhelming majority of the reported falls happen in the
bathroom. They did find that the rate of falls was reduced in the scenarios where a bathroom was
used by more than one patient. Additionally they found that when the toilet was positioned in
such a way that continuous use of the bathroom handrail was not possible that the incidence of
falls increased. When a patient was able to hold on to a rail on both sides of the toilet a fall was
less likely. Another factor that decreased number of falls was having a designated family area in
the room. When this was the case there was 50% less falls.
The researchers concluded that there are several variables to consider when designing
rooms in the future. Among these were: dedicated family areas in the rooms, ensuring continuous
hand rails in the bathroom, widening bathroom door openings, and strategically locating the
bathroom (Pati, Lee, Mihandoust, Kazem-Zadeh, and Oh, 2018).
Second Research Study
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The second study looked at from the literature was from the NPSF and studied the design
and layout of both the room and the toilet area to access how design was related to falls (Choi,
Lawler, Boenecke, Ponatoski, & Zimring, 2011). The researchers used real people to test the
layout and features of a room and analyzed what was most likely to contribute to increased falls.
The people who participated was observed and then questioned by expert layout designers and
also Nurses. This is included the voluntary use of recording. The recordings detailed how the
people moved around and within the room. Their ability to move smoothly while doing everyday
tasks and activities in the room was closely monitored.
The researchers were able to document specific movements that increased the risk of a
fall. These included things such as changed in posture like pulling or needing to turn when
moving to the bathroom (Choi, Lawler, Boenecke, Ponatoski, & Zimring, 2011). If the person
needed to maneuver around obstacles, fall risk increased. The movements that were associated
with increased fall risk were moving in and out of doorways and maneuvering around the toilet.
The researchers were able to determine the specific changes in posture that were present
in most incidence of falling. The most common observed were movements that involved
grabbing, a patient needing to pull or push, and also turning while maneuvering in the room or
bathroom. Falls were most common when these movements were in the process of entering or
exiting an entryway, trying to open or close a door, locating hand rails, or when obstacles were
present in between the bed and an entryway.
When the connection between rates of fall and both the intrinsic, environmental factors,
and changes in posture were considered as a whole, the aforementioned changes in posture were
RESEARCH PROPOSAL PT 2 6
still a significant contributing factor in falls. Furthermore, because many of these changes in
posture were related to areas that can be altered or improved, they concluded that hospital design
that focuses on decreasing these changes in posture in the most affect areas of the room needed
to be looked at. The suggestions the researchers made were: bathrooms that do not require a
patient to turn near the toilet, sink, or entryway, replace doors that open inward and outward with
pocket doors and increase the width of the opening when possible. The researchers stated in the
literature that additional research and study is needed and that their findings and suggestions
were preliminary (Choi, Lawler, Boenecke, Ponatoski, & Zimring, 2011).
Closing Thoughts and Additional Study Recommendation
In consideration of the information in these studies, there is a clear need for additional
research to confirm the findings and make additional recommendations. The information clearly
points to the bathroom as being a serious concern when it comes to patient falls (Fink, Pak, &
Battisto, 2010). It is also likely that, in addition to other suggestions, modifying the bathroom
door can lead to decreased falls. The studies from the literature also seem to support my original
hypothesis that wider bathroom doors in patient rooms will lead to a decrease in patient falls.
References
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Pati, D., Lee, J., Mihandoust, S., Kazem-Zadeh, M., & Oh, Y. (2018). Top five physical design
factors contributing to fall initiation. HERD: Health Environments Research & Design
Journal, 11(4), 50-64.
Choi, Y., Lawler, E., Boenecke, C. A., Ponatoski, E. R., & Zimring, C. M. (2011). Developing a
multi‐systemic fall prevention model, incorporating the physical environment, the care
process and technology: A systematic review. Journal of Advanced Nursing, 67(12),
2501-2524.
Fink, N., Pak, R., & Battisto, D. (2010). Developing a usability evaluation tool to assess the
patient room bathroom. HERD: Health Environments Research & Design Journal, 3(3),
22-41.
Manjam, N. V., & MacKinnon, H. H. (1973). Patient, bed and bathroom. A study of falls
occurring in a general hospital. The Nova Scotia Medical Bulletin, 52(1), 23.
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