Plan for Preventing Falls in a Hospital Unit

Reducing Falls on the Surgical Step Down Unit
Introduction
The problem of falls in acute care hospitals is one that continues to persist in spite of the existing literature available on this topic (Zhao et al., 2018). Hester, Tsai, Rettiganti and Mitchell (2016) note that inpatient falls account for the largest number of reported incidents in hospitals. One reason for the problem is that hospitals fail to implement proper and effective preventive strategies based on best practices (Melin, 2018). The purpose of this paper is to provide guidance on reducing the number of falls on the surgical step down unit by implementing evidence based fall precautions, effective communication, and education of the patient/family. The research question guiding this research paper is: What are the preventive strategies that can be put in place to reduce falls in a surgical step down unit? To answer that question, a literature review was conducted and a discussion of the evidence is herein included to describe what those best practices are.
The goal of this paper is to reduce the number of falls on the surgical step down unit by implementing evidence based fall precautions, effective communication, and education between the patient/family.
Literature Review
Patient falls are a problem that can be overcome through the implementation of preventive strategies (Khalifa, 2019). By using preventive strategies as a policy approach to reducing falls, a hospital setting can give nurses the support and guidance they need to address this patient health issue. Khalifa (2019) showed as much by identifying the top five strategies that help to prevent falls. These strategies include patient and staff education about what leads to falls and how to prevent them; engaging in exercise with patients so that they are more flexible and able to maintain balance; diagnosing and treating medical conditions more effectively; enhancing the environment by removing obstacles that could lead to falls; using information technology to assist staff in providing care for patients so that they do not attempt to take steps without assistance and so that staff can better monitor patients. Of these strategies, exercise with patients is one that has been highlighted by several other researchers as well, including Lim, Cho, Kim, Kim and Yoon (2017) and Fu, Gao, Tung, Tsang and Kwan (2015). The studies by Lim et al. (2017) and Fu et al. (2015) support the findings by Khalifa (2019) calling for exercise as a preventive strategy. What makes the studies by Lim et al. (2017) and Fu et al. (2015) so helpful is that they focus on virtual training exercises and exergaming as a way of helping patients become more mobile, agile and stronger. Khalifa (2019) identifies the strategy of exercise as a necessary component of a prevention strategy, but it is the other two studies that provide excellent details on what type of exercise program can be pursued to help with patients.
However, in a surgical step down unit, it is unlikely that such an intervention as exergaming or virtual training will have much applicability. The key to reducing falls is to tailor prevention strategies to the specific needs of the setting (Wilson et al., 2016) One way to do that is to recognize the patients who are at a high risk for falls and to make sure that they are being cared for properly. They will need to be educated on what to do if they require assistance and the nurses will have to be very careful about accommodating their needs, according to Wilson et al. (2016). The study by Wilson et al. (2016) is helpful because it provides nurse perceptions and gives a qualitative understanding of what nurses think the problem is. Since they are on the front line in terms of caring for patients, their perspective is an essential one to consider, and that is why the study by Wilson et al. (2016) is useful in getting a grasp on this issue. Though Fu et al. (2015) and Lim et al. (2017) focus on good falls prevention strategies in situations where there is time to train people who are at risk, Wilson et al. (2016) actually look at what can be done in a hospital setting, based on what nurses’ experiences are for this type of problem. Thus, for a hospital, there are specific steps nurses can take to address the matter. The study by Wilson et al. (2016) helps to explain what those steps could be and why they can work. Wilson et al. (2016) focus on steps such as the importance of having a daily audit, the importance of communicating and supporting one another when it comes to helping with high risk patients, and the importance of leadership in the unit.
Yet, as King, Pecanac, Krupp, Liebzeit and Mahoney (2018) report, there is no substantial evidence based guidelines for falls prevention in a hospital setting. That is the reason nurses have a difficult time implementing the best strategies (King et al., 2018). The study by King et al. (2018) is important to consider because it focuses the attention on the lack of research regarding the gathering of empirical evidence on the matter. Too few tests have been conducted that can show the empirical proof that falls prevention guidelines make a difference in reducing falls. Even when falls prevention guidelines are put in place it can create unintended negative consequences, such as fear among nurses that a fall might occur causing the unit to miss its goal of reducing falls, which leads to increased stress and strain among nurses (King et al., 2018). Increased stress and strain can lead to burnout and that can lead to a decline in job satisfaction and that in turn to nurse turnover rates exploding higher. The problem of maintaining a balance between prevention and care is a delicate one and King et al. (2018) argue that there is not enough evidence to support the idea that a falls prevention program can work without leading to other problems. This study is important because it highlights an issue that few other researchers observe, i.e., the problem of unintended consequences. This problem is also noted by Growdon, Shorr and Inouye (2017) who point out that falls prevention programs can promote tension between nurses who want to get their patients moving and encourage mobility and nurses who want their patients to remain immobile for fear of their having a fall. The study by Growdon et al. (2017) should be considered alongside the study by King et al. (2017) because both highlight the dangers or risks of implementing a falls prevention program, which is something most studies do not take into consideration. For instance, the study by Wilson et al. (2016) does not look into that issue at all. Instead, it focuses only on the positives of implementing a falls protection program.
In summation, the literature shows a number of things: first, it shows that falls prevention programs and initiatives do exist but that they tend to focus on helping patients to be more agile through exercise and balance techniques (Fu et al., 2015; Lim et al., 2017). Second, it shows that falls prevention programs can work in reducing falls (Khalifa, 2019). The idea that falls prevention does not work is not the issue. Falls prevention can work well—but the issue is that prevention can come at a significant cost or risk, as Growdon et al. (2017) and King et al. (2018) indicated. That is why their focus on issue is just as important if not more so than the findings put forward by Khalifa (2019) and Wilson et al. (2016). The falls prevention strategies can help nurses to reduce the number of falls that happen in a unit, and that evidence has been empirically proven, but there is another side to the issue, which is that falls prevention strategies can create tension in a unit and can increase stress for nurses. Thus, this is a complex issue that has to be carefully considered before a proper solution can be found.
Discussion
The objectives of a falls reduction plan should be: 1) to analyze current fall prevention practices in the hospital; 2) to recognize high risk patients and observe fall prevention that strategies are in place during shift change/report; 3) to identify the challenges for fall prevention on the unit; 4) to modify the number of falls with answering call lights even if it's not your patient; 5) to practice “No pass zone” etiquette (i.e., answer call lights without passing by, even if not coming from one’s own patient); 6) to monitor fall rates and practice implementation. These are the recommendations of researchers like Wilson et al. (2015) and Khalifa (2019). When nurses implement these strategies they can reduce the number of falls. Therefore, for the issue of preventing falls in the step down unit, it is important that the falls reduction plan have these steps as part of the guideline.
However, there are other points that must be included as well in order to properly mitigate for the risks identified by Growdon et al. (2017) and King et al. (2018). Those risks include creating tension among nurses and increasing stress and fear among nurses. First off, nurses should understand which patients are high risk for falls and which patients are not. Second, they should also work to collaborate and communicate effectively with one another so that it is understood which patients are working on increasing their mobility and may need extra care in an all-hands-on-deck type of situation, and which patients will require less extra attention. Above all, the guidelines should reiterate that a nursing unit is a team and as such it is never acceptable for team members to get down on one another even if a negative outcome, like a fall, occurs. Falls are going to happen. The key is to reduce their frequency. Eliminating them altogether would be great but it is unlikely. Thus, nurses should accept that there is a degree of risk to the program. No approach is going to be perfect. Communication and collaboration can be instrumental in reducing tension between nurses, especially if there is likely to be a difference of opinion among nurses regarding which patients should be mobile and which patients should be stationary.
As Wilson et al. (2015) showed, the science behind a successful falls prevention situation is to tailor the plan to the needs of the unit. This means it does not have to be a one-size-fits-all type of program. What works in one study environment might not work in another because every environment is different. There will be a unique workplace culture, a unique set of nurses, a unique set of patients and so on. By assessing what is available and what the needs and concerns of the stakeholders are, a proper plan to reduce falls can be implemented. The key, as King et al. (2018) show is to keep the plan from causing undue stress. Nurses need to be supported not berated or made to feel that they are constantly under threat. They should feel encouraged rather than scared or frightened of not meeting a goal. This is where a leader will come into play to make sure that nurses are properly motivated by a spirit of good will rather than by a spirit of fear of failure and punitive retribution.
For that reason, planned experiences for implementing a falls reduction policy should include: 1) an interview with staff on the unit for best practice understanding and to see what works best for the unit; 2) to conduct daily audits to make sure fall prevention strategies are in place; 3) to comply with patient safety standards by completing checklists for day shift and night shift and thus maintain a safe environment; and 4) to research how effective communication can help in preventing falls within staff on the unit. These are best practices identified among the various studies that have been conducted on this topic and they clearly show that preparation is the best form of prevention. In other words, unless a staff is trained on how to address the issue of falls that staff is not going to take the proper precautions that should otherwise seem like common sense. In the field of nursing, it cannot be assumed that common sense suffices as a strategy or can be counted upon in lieu of a policy. The best prevention strategy is to have a falls prevention policy in place. At the same time, the unit should take care to reduce the risk of unintended consequences such as burnout or stress caused by implementing a falls prevention plan. Thus, each of these steps should be discussed more clearly one at a time.
First is the need to interview staff on the unit to understand what they know to be best practices and to compare best practices as pointed out in the literature by Khalifa (2019). It should also be remembered that as Wilson et al. (2015) note, the best plan is the one that fits the unit. Adaptation is thus essential. The leader must get to know what will work for the nurse team and what will be asking too much. If the mental health of the team is adversely affected, the health and safety of the patients is going to be negatively impacted as well. One cannot risk the health of nurses by pushing them too far. Thus, feedback should be obtained during these interviews so that the policy plan put in place does not extend too far beyond what the nurse team can actually commit to doing without overburdening themselves. The goal, it should be remembered, is to reduce falls—not to try to eliminate them completely. Leaders should keep it realistic and not try to implement an idealistic policy that will only stress nurses out and lead to poor morale.
Second is the need to monitor the plan and see if it is working or if changes need to be made. One way to do this is to conduct daily audits as the literature suggests. Daily audits can keep people focused on the mission and mindful of what they need to do to keep the plan moving in the right direction. Daily audits can be time-consuming, however, and already busy nurses might feel that too much is being demanded of them to give so much attention to this type of monitoring of the plan. A discussion should be had with nurses to see if they feel this is something they can do with minimal stress. If nurses feel it would be too much, then the leader should be prepared to find an alternative solution to the issue of daily auditing. Keeping and completing checklists for both day and night shift nurses could be an alternative solution to this problem.
Third is the need to comply with patient safety standards. One way to do this is through the use of checklists, and if nurses are open to this idea then it could be a way to motivate the team and keep the change going forward. Whenever a change is being implemented it is important to maintain progress and momentum, so a safe environment should be a goal of course but not at the expense of the nurses’ own mental health. At all times, leaders should be solicitous of their nurses. Leaders should try to adopt a servant leadership style, since they are going to be asking more service from their nurses. The best way to motivate is to show the behavior that one wants to engender. Having a no pass zone type of etiquette among nurses can help but only if leaders show that this is something they are going to promote through their own actions. Once leaders ingrain this type of mentality in their nurses through their own example it will become second nature among staff.
Fourth is the need to research how to communicate and collaborate effectively. Nurses depend upon communication and collaboration in order to maintain continuity of care. If nurses fail to communicate, it can increase safety risks for patients and it can harm workplace morale and lead to resentment among staff. Nurses thus need to know that communication is vital and of the essence. The best way to keep nurses communicating and collaborating is to promote a culture that supports this.
To promote a culture of collaboration and communication a number of steps must be taken. First, nurses should know that they are supported by their leader and their leader should be engaged with them. A leader who is absent or disengaged will be sending the wrong message about what it means to communicate and collaborate. The leader always sets the tone and should always be the one giving the right example. The way to do this is for the leader to give and get feedback to and from nurses. This shows nurses that communication is part of the environment and thus it will not be a shock or surprise when the leader requires nurses to communicate about patients who are high risk for falls. Second, a supportive culture needs to be in place so that nurses are not shocked when they are asked to lend a helping hand with a falls prevention plan even though a particular patient is not one of their own. The idea of supporting one another has to be ingrained in the workplace culture and that example again has to be set by the leader. A leader who is not constantly engaged and supportive is one who will risk the entire plan failing.
With these steps and risk mitigation plans in place, the surgical step down unit is likely to succeed in its mission to reduce falls. The steps outlined are based on best practices and evidence from recent studies published in peer reviewed journals. There are risks outlined by researchers and those are taken into consideration. The key to a successful falls reduction plan is to allow nurses to adapt the strategy to meet their needs. They should be invited into the discussion of what needs to be done and what they think will work best for their unit. Their opinions and ideas should be taken seriously and respected because that is how morale and support are built and maintained.
Conclusion
Reducing falls in a surgical step down unit is possible based on the empirical evidence and best practices outlined in recent literature on the subject. Coordination and communication are among the most essential steps that nurses should take. Technology can also be used to monitor patients and facilitate the process. However, nurses should also be mindful of the risks to their own mental health and safety that can occur if they push themselves too far. If a unit is unable to address the issue of falls reduction without sacrificing their own mental health then the leader should take the plan back to the drawing board. Whether it is a problem of communication, a problem of not having time to conduct a daily audit on top of other concerns, or a problem of culture, the leader has to monitor the situation as the plan is implemented and make sure there is a sense of what is working and what is not working. There is no one-size-fits-all plan, so the leader should accept that plans can be tailored to fit the needs of the unit. If this means there are opportunities to engage in exercise training on the unit, then that is one possibility to consider. If it means there are tools for increasing digital monitoring and thus reducing falls through telehealth technology, that is another option to consider. The point is that there is no need to assume that what works in one unit or in one study will be what works in another unit.
References
Fu, A.S., Gao, K.L., Tung, A.K., Tsang, W.W. & Kwan, M.M. (2015). Effectiveness of exergaming training in reducing risk and incidence of falls in frail older adults with a history of falls. Archives of physical medicine and rehabilitation, 96(12), 2096-2102.
Growdon, M. E., Shorr, R. I., & Inouye, S. K. (2017). The tension between promoting mobility and preventing falls in the hospital. JAMA Internal Medicine, 177(6), 759-760.
Hester, A. L., Tsai, P. F., Rettiganti, M., & Mitchell, A. (2016). Predicting injurious falls in the hospital setting: Implications for practice. American Journal of Nursing, 116, 24-31.
Khalifa, M. (2019, July). Improving Patient Safety by Reducing Falls in Hospitals Among the Elderly: A Review of Successful Strategies. In ICIMTH (pp. 340-343).
King, B., Pecanac, K., Krupp, A., Liebzeit, D., & Mahoney, J. (2018). Impact of fall prevention on nurses and care of fall risk patients. The Gerontologist, 58(2), 331-340.
Lim, J., Cho, J.J., Kim, J., Kim, Y. & Yoon, B. (2017). Design of virtual reality training program for prevention of falling in the elderly: A pilot study on complex versus balance exercises. European Journal of Integrative Medicine, 15, 64-67.
Melin, C. M. (2018). Reducing falls in the inpatient hospital setting. International journal of evidence-based healthcare, 16(1), 25-31.
Titler, M. G., Conlon, P. C., Reynolds, M. A., Ripley, R., Tsodikov, A., Wilson, D. S., & Montie, M. (2016). The effect of translating research into practice intervention to promote use of evidence-based fall prevention interventions in hospitalized adults: A prospective pre-post implementation study in the U.S. Applied Nursing Research, 31, 52- 59. doi:10.1016/j.apnr.2015.12.004
Wilson, D. W., Montie, M., Conlon, P., Reynolds, M., Ripley, R. & Titler, M. G. (2016). Nurses’ perceptions of implementing fall prevention interventions to mitigate patient—specific fall risk factors. Western Journal of Nursing Research, 38, 1012-1034.
Zhao, Y. L., Bott, M., He, J., Kim, H., Park, S. H., & Dunton, N. (2018). Multilevel factors associated with injurious falls in acute care hospitals. Journal of Nursing Care Quality, 33(1), 20-28.