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...…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.