Nursing Role in Fall Prevention

Introduction and Background

In the healthcare field, Falls are referred as untoward incidence which cause the patient to come to rest on the floor or ground unintentionally from a height that is preventable in most cases. The presence of falls and fall-related injury are common among the elderly patients as they due to their dwindling health condition and long-term health consequences becomes physical unable to have enough strength in maintaining steady mobility and posture which contributes towards their fall (Simamora and Nurmaini, 2019). The nurses play a key role in supporting elderly patients from facing fall during their hospital or nursing home stay. This is because the nurses have the key responsibility in holistically supporting and caring for ailing elderly individuals to ensure their improved health and avoid them from fall risk (Moisoglou et al., 2020). Thus, in this study, perspective of the nurses is evaluated to understand factors that are causing them to create fall error which is detrimental for the health consequences of the patients. The NHS mentions that 1 in 3 adults above the age of 65 years living in hospital or their homes are prone to experience at least one fall each year (NHS, 2019). In many cases, the impact of falls is minor, and do not involve major injury, but it creates hindered health impact on health of the patient by causing them to develop fear towards moving. This is evident as mild to moderate fractures are faced by patients as a result fall error by the nurses. It leads them develop fear of further injury and makes them avoid moving out of fear which creates hindered impact on them physical a well as mentally (NHS, 2019). The nurses in care homes and hospital play a major role in preventing these falls but they are still found to be incapable in controlling their actions in preventing the falls. It is evident as the NHS reports that in 2019 because of fall hazards and inability of the nurses to protect them among the patient led NHS England to spend nearly £435 million extra finances in supporting fall related health deterioration among the patients (Gov, 2020). Thus, it indicates that fall error by the nurses create increased cost of care to be bear by the NHS which could be preventable with effective actions. Therefore, in this study, apart from focussing on the reason of fall errors by the nurses, the strategies to prevent the errors and avoid falls according to nurses and their managers from international arena are to be focussed and discussed.

The key aim of the study is to frame international integrated literature review that examines and identify the reason of fall errors by nurses and strategies to prevent them. The research questions are as follows:

What are the individual factors leading to fall error by the nurses in the care settings? What are the systematic factors leading to fall error by the nurses in the care settings? How the fall errors by the nurses could be resolved in the care settings?

The structure to be followed to present the integrated review is presenting the key search strategies to be used in selecting the primary articles for the study. Further, a presentation of brief facts from the gathered study is to be informed through tabular format. The result from the study are to be analysed and the facts are to be discussed. At last, recommendations based on the gathered and discussed information is to be present along with the summary of the findings.

Search Strategy Process

A definitive search strategy is required because it combines the key concept related to research questions for retrieving accurate results (Bakon et al., 2017). In this study, the key databases to be used for retrieving articles in framing the current integrated international literature review include PubMed and Google Scholar. This is because they consist of wide variety of medical journals and information from different researchers across the world regarding different nursing and medical topics. The keywords for search to be used are “fall error”, “nursing fall prevention”, “reason of nurse fall error”, “nurse fall education and attitude” and others. In the study, the inclusion criteria involve published articles on and after 2016, written or translated in English, primary research articles, includes data regarding fall error and prevention by nurses and academic in nature. The exclusion criteria considered in the study published articles before 2016, not written or translated in English, non-academic in nature, secondary articles and do not contain information regarding fall error from nursing perspective. The academic journals are involved in the study instead of the non-academic articles because they contain scientifically analysed and approved information with valid experimental results which ensures delivering valid and authentic results. The articles written and translated in English is to be used because the researchers have only knowledge to understand facts in English as they belong from the UK where English is the key language been spoken and understood. The published articles on and after 2016 is to be used because they include current and detailed information regarding the study topic in turn avoiding creating error by inclusion of backdated information. The articles containing information regarding nurse’s perception and prevention strategies regarding fall error is to be used as they contains the key facts relevant to the study topic. The primary articles is to be used instead of the secondary articles because it contains first hand accounts of data which remain non-manipulated by opinions of researchers and helps the researcher in relating to the facts to create a deeper understanding of the event regarding the topic.

Evaluation and Integration of the Evidence

In the study, total of 9 primary studies are used and among them 3 are quantitative study and 6 are qualitative study.

Theme 1: Individual factors or reason leading to fall error by the nurses in the care settings

The personal reasons which leads nurses to execute fall error making patient to suffer fall in the care settings that could be prevented are to be identified and discussed. The study by Jin and Ha (2017) involved a descriptive survey approach in which the design is used with the aim to explore factors relating to fall among the patients under the care of the nurses. The random sampling strategy is used in which 341 nurses are included in the study who are recruited from one university hospital (n=161) and two general hospital (n=180) in Korea. The survey data collection method was used to gather information about the factors causing hindered fall prevention by nurse in the hospital to be identified. The result revealed through regression analysis is that due to lack of self-efficacy (β = 0.35, p0.01) the nurses were unable to avoid fall and caused error in care. This is evident as self-efficacy is directly related to improve performance activity and occupational engagement of the nurses in providing effective treatment to ensure fall prevention of the patients. The strength of the study is that it used descriptive approach as it helped to provide enhanced understanding of the entire data mentioned in the study. This is evident as descriptive approach helps to present holistic understanding regarding the topic by providing explanatory data for each of the results gathered (Birks et al., 2017). The limitation in the study is that since it expressed results from study participants from tow specific hospitals, therefore the results are not able to be generalised. The other limitation is that it lacked adequate structural information that inform the way hospital structure personally influence fall error among nurses in the care settings. The study by Suryani et al. (2019) also contains data related to the theme as it aims to explore the related factors of the nursing practise that leads to hindered fall prevention among the patients. The study is set in Indonesia and uses the cross-section approach for presenting descriptive and analytic quantitative study. The study gathered 95 nurses through the use of random sampling method in gathering data. The data for the study is gathered through the use of self-reporting questionnaire to measure the knowledge, attitude and observational behaviour of the nurses who are contributing to the fall error in patient. The results from the study reveals that fall risk due to nurses occur in 55.8% cases when they have poor personal knowledge regarding the way to prevent fall and 58.8% cases when they have poor attitude towards executing care for fall prevention of the patients. This is evident as attitude is predisposition to the practical action and dictates the nurse’s individual behaviour toward fall prevention. In addition, knowledge act as persistent information in the mind of the nurses which influences their positive and negative actions towards fall prevention. However, lack of effective knowledge and attitude as individual factors leads the nurses to remain negatively predisposed to perform their fall prevention actives effectively in turn creating fall error among the nurses. The strength of the study is the descriptive approach which allowed it to be performed within limited time and cost-effective way. However, the limitation is that the use of simple random sampling as the method to recruit participations. This is because simple random sampling does not allow equal opportunity to be created for the selection of the participants in the study in turn creating biases in response gathering.

The study by Jung and Jung (2016) explores the key systematic factors which leads to fall error and is effective to be related to ensure fall prevention by nurses in the care setting. The study is executed by using descriptive study approach. The data for the study is collected from 210 nurses who are working at the Metropolitan City Hospital and the participants are chosen through convenient sampling method. The gathered data is analysed by using independent t-test, one-way ANOVA test, descriptive statistical analysis and SPSS. The results of the study inform that reduced personal knowledge along with lack of effective attitude towards caring are the key reason for the nurses in facing fall errors in turn making the patient vulnerable to experience fall. The fact presented support the study by Suryani et al. (2019) where similar results are highlighted. The strength of the study is use of descriptive analysis which helps to provide detailed insight into the reason behind the results been represented. The limitation of the study is use of convenient sampling because it does not help to develop representative results that can extend the results to extrapolate the target population (Seo and Cha, 2016). The other limitation is that the results cannot be generalised because of the presence of specific institutional characteristics like confusion about the patient severity, level of manpower and others.

Theme 2: Systematic factors leading to fall error by the nurses in the care settings

The current theme explains the systematic reason that is leading towards fall error to be executed by the nurses in care settings. The study by Hakvoort (2019) mentioned that it took a qualitative approach in exploring the behaviour and perspective of the Dutch hospital nurses regarding fall prevention among the patients in the hospital. In the study, 13 experts were included to present their opinion regarding the reason behind the estimated fall risk caused by the nurses. The study used two round Delphi method to gather data. The results inform that lack of experience in providing care mostly seen in young nurses leads to create fall error in the care settings. Moreover, the presence of low priority toward fall prevention and lack of fall risk assessment made by the nurses makes them cause fall error at the hospitals while caring for the patients. The strength of the study is the use of qualitative approach is explaining detailed account that mentions enhanced meaning of the data. The limitation of the study is use of Delphi method. This is because the method does not allow in-depth questions to be developed to gather valuable data for enriched execution of the study (Hakvoort, 2019). The other limitation of the study is that the information from the article cannot be generalised as it is not collected in collaborative manner through focus group (Hakvoort, 2019). The other study which is related with the theme is by Fehlberg et al. (2020) which explores the fall prevention decision-making by the registered nurses in acute care settings to understand what are the barriers that are leading them to develop error in the aspect. The researcher used qualitative study design in executing the study. In the study, selective sampling is used in which the participants are considered to fulfil both the criteria that are to be involved in caring for at least one moderate to high risk fall patient and do not have scheduled work the next day of the participation in the study. The data is to be gathered by using interview method. The results revealed that lack of effective compliance with the fall prevention strategies as a result of ineffective judgemental care by the nurses created fall error. Moreover, it was informed that the fear of humiliation to be faced by nurses on revealing their failure to prevent fall leads the nurses involved in further fall error at the care. The lack of adequate staff created increased work pressure on the nurses resulting them to face fall errors along with the ineffective value towards taking actions by listening to be alarms also led to cause the error. The strength of the study is using interview method in gathering data. This is because interview helps to gather quality data where in-depth information about the participant’s thoughts, experiences, opinions and feelings are provided. However, the limitation of the study is that data is gathered from one unit of the hospital which leads it unable to be generalised. Moreover, the other limitation is that the sample is homogenous which also reduced the generalisation of the results. The other study by King et al. (2018) is related with the theme and it aims to explore the impact of fall prevention on nurses and care of fall risk patients. This is to determine which factors could pose hindrance for the nurses in making them unable to prevent fall. For this purpose, the study used Grounded Dimensional Analysis in the executing the research. The sample for the study consisted of 27 registered nurses who are selected through purposive sampling and they are interviewed through semi-structured questionnaire in gathering data for the study.

The results revealed that intensive pressure from the hospital administration in managing the fall risk to zero create fear among the nurses in making mistake to detect patients who are not at all in risk to experience fall. It created extra burden on the nurses to take extra precautions in supporting patients those did not require the services. The strength of the study is that use of grounded analysis. This is because it led to avoid making assumptions in presenting results and allows the researchers to adopt a neutral view in explaining the results in turn avoiding biased presentation of results. The limitation of the study is that it did not executed observation beyond the interviews which led to create lesser strength in the analysis in turn leading the researchers unable to seek better clarification from the participants for the responses made. The other limitation is that since the participants are included from specific facility of the hospital therefore the results gathered cannot be generalised in all aspect of the care.

Theme 3: Fall prevention error strategies for nurses in care settings

The information under the theme explains the strategies to be adopted by the nurses in avoid fall error and ensure fall prevention among the patients. The study by Kim and Seo (2017) aims to explore the knowledge and attitude of the nurses required to be present in preventing fall activities in the care setting through their active involvement. The study used descriptive correlation design to execute the research and gather data. The study selected participants through purposive sampling in which 142 nurses from a geriatric hospital are asked to mention their response through self-reported questionnaire. The results revealed that 98.6% nurses reported they feel elderly who have previous incidence of fall are high possible of facing fall again. Therefore, to avoid fall errors by nurses they are to ensure taking effective fall protective care for such patient who have previous experience of fall. The results further revealed nurses to avoid fall errors that leads patients to experience fall are required to have knowledge that people with visual impairment are at greater risk of facing fall; diuretics and depressed patient are not at risk of fall; severity of the disease is proportional to increase risk of fall. The findings also mentioned that nurses to avoid fall error and ensure fall prevention are required to educate patients in asking for help to move out of bed from nurses by raising alarm, educate patients the way to use wheelchair and walking sticks, ensure providing effective medication avoid risk of fall, check for illumination of light in patient ward and others. The strength of the study is that it effectively highlights the aspects to be focused for fall prevention by the nurses in hospital. However, the limitation of the study is that it gathered information by targeting only grade 1-3 hospitals and it created hindrance for the generalisation of the results as the facts cannot be expanded to be used in making repeated research. The other limitation is use of self-reporting questionnaire in which the responses from the individuals cannot be analysed by considering their expression and discussion cannot be developed with them to make in-depth analysis. The study by Hiyama (2019) has the key aim to explore the utility of fall detection and prevention tool for the nurses in preventing falls at the care settings. For this purpose, the study used descriptive study design and survey methodology. The random sampling method is used to gather data and 49 hospitals participated in the study from the total selected population of 160 hospital. The self-reporting questionnaire are provided to the nurse manager in the hospital who distributed to them to the nurses to help them provide their responses. The results revealed that 91.2% nurses informed fall prevention tool has greater utility in helping them avoiding fall in the care settings. The survey further informed that 93.5% nurses preferred use of score type of fall prevention tool compared to non-score type of fall prevention tool in avoiding fall errors.

The descriptive responses for the study revealed that nurses mention fall detection would be easier with use of fall prevention tool. Moreover, the tool use supports making effective fall prevention plan and guides the beginning nurses from the initial stage to avoid making fall error. The strength of the study is use of random sampling which is evident as it leads the participants to represent the target population, in turn, eliminating sampling bias. However, the limitation of the study is that it did not provided particular information about the specific fall prevention tool to be used which has greater validity and specificity for the nurses to make fall prevention and avoid fall errors. The study by Vandenberg et al. (2017) has the key aim to explore the nurses experience with fall prevention technology in the nursing care home environment and the way it supports workflow. For this purpose, a case study approach is taken, and two sample case studies are analysed to gathered qualitative data in the study. The results reveal that coordinate communication system is required to be present in the nursing environment that facilitates effective fall response alert to be managed as a strategy for effective fall management by the nurses. Moreover, the safety culture of the nursing home is another essential feature which ensure effective use of technological system by the nurses to avoid fall errors and make enhanced fall prevention of the patients. The strength of the study is that the interview is initially executed by native speakers who are working with the informants and it led to capture regional nuances to provide error free responses. However, the limitation of the study is that it does not provides adequate data to inform the way structural hindrances in workplace is to be managed so that systematic factors that are leading to fall error by the nurses can be avoided.

Key Findings of the Reviewed Studies

In the research, the collaborative consideration of the studies by Jin and Ha (2017) and Suryani et al. (2019) informed that lack of self-efficacy and poor personal knowledge regarding fall detection and management by the nurses leads them to face fall error or inability to prevent fall among the patient. The self-efficacy is directly related to improve performance activity and occupational engagement of the nurses in providing effective treatment to ensure fall prevention of the patients. The fact by Suryani et al. (2019) is also supported by the study of Jung and Jung (2016) where it also mentions that apart from knowledge, the attitude of the nurses at work acts as personal reason towards making fall error for the patients by the nurse. This is because without positive attitude towards providing care, the nurses show carelessness which leads them unable to detect the risk of fall for the patients in turn contributing to supporting fall error. The study of Hakvoort (2019), King et al. (2018) and Fehlberg et al. (2020) highlighted individual systematic reason that leads the nurses to execute fall error and none of the data are found to have supportive statement in the studies. The study by Hakvoort (2019) mentioned that lack of experiencing in managing and detecting fall among the patients by the nurse leads them to make error in fall prevention. It is evident as they do not understand the way systematic care is to be planned to avoid fall and detect risk of fall. The study by King et al. (2018) mention that lack of compliance with the policy for fall prevention makes the nurses make fall error. It is evident as policy act as guidance for the actions to be executed for fall prevent and not abiding by it leads the nurses make error in their care policy leading them to face inability to avoid fall which occur due to their own responsibility. However, Fehlberg et al. (2020) reported work pressure leads nurses to develop fear and make mistakes in managing fall prevention actions. The strategies identified from the studies of Kim and Seo (2017), Hiyama (2019) and Vandenberg et al. (2019) are that nurses are to be avoided be burdened with care activities, they are to be educated in using fall detection tool and are to be educated to make them ask patient to comply with them in care to ensure effective fall prevention among the patients.

Conclusion and Recommendation

The international integrated literature review concludes from the 9 primary studies regarding the factor responsible for making nurses in executing fall error and strategies to be implemented in preventing fall by the nurses. For this purpose, in-depth examination and analysis of the gathered facts are done and mentioned under separate themes for their systematic presentation. The similar with the research paper used is that they are focused on fall error and prevention by nurses and not from the perspective of the patients. However, dissimilarity with the studies is that few of them highlighted different factors related with the fall error while other focussed in mentioning fall prevention management to be done by nurses to avoid error. In the study, a total of 3 qualitative and 6 qualitative primary research paper are used. The gap identified in the current research is lack of consistent presence of result that are unable to be generalised in most context. Therefore, in future, further studies are to be explored where generalised data can be found that can be used as evidence in real-life in all condition by nurses to avoid making fall error. The recommendation on the basis of findings in the study is that nurses are to be trained and education regarding the way to manage work pressure, abide by fall regulation policy and ensure effective detection of patient at risk of fall among all patients. The other recommendation is that strict fall prevention policy education is to be provided to nurses to help them avoid making fall error and ensure effective fall prevention of patients.

References

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Vandenberg, A.E., van Beijnum, B.J., Overdevest, V.G., Capezuti, E. and Johnson II, T.M., 2017. US and Dutch nurse experiences with fall prevention technology within nursing home environment and workflow: A qualitative study. Geriatric nursing, 38(4), pp.276-282.