Reducing Patient Falls in Surgical Step Down Units

Introduction

The problem of falls in acute care hospitals is one that continues to persist despite the existing literature available on the 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 the problem persists 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 and family. The research question guiding this paper is: What preventive strategies 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 presented below to describe what those best practices are.

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 safety issue. Khalifa (2019) identified the top five strategies that help prevent falls: patient and staff education about what leads to falls and how to prevent them; engaging patients in exercise 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; and using information technology to assist staff in providing care so that patients do not attempt to move 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). Both studies support Khalifa's (2019) call for exercise as a preventive strategy, and they are particularly helpful in that they focus on virtual training exercises and exergaming as ways of helping patients become more mobile, agile, and stronger. While Khalifa (2019) identifies exercise as a necessary component of prevention, it is the studies by Lim et al. (2017) and Fu et al. (2015) that provide excellent detail on what type of exercise program can be pursued.

However, in a surgical step down unit, interventions such as exergaming or virtual training are unlikely to 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 identify patients who are at high risk for falls and ensure that they are being cared for properly. Those patients will need to be educated on what to do when they require assistance, and nurses will have to be very careful about accommodating their needs (Wilson et al., 2016). The study by Wilson et al. (2016) is particularly helpful because it captures nurse perceptions and offers a qualitative understanding of what nurses believe the problem to be. Since nurses are on the front line of patient care, their perspective is an essential one to consider. While Fu et al. (2015) and Lim et al. (2017) focus on falls prevention strategies for situations where time exists to train at-risk individuals, Wilson et al. (2016) examine what can be done in a hospital setting based on nurses' lived experiences. Their study highlights steps such as the importance of daily audits, effective communication, mutual support when caring for high-risk patients, and leadership within the unit.

Yet, as King, Pecanac, Krupp, Liebzeit, and Mahoney (2018) report, there are no substantial evidence-based guidelines for falls prevention in a hospital setting, which is one reason nurses have difficulty implementing optimal strategies. The study by King et al. (2018) is important because it draws attention to the lack of rigorous empirical evidence demonstrating that falls prevention guidelines actually make a measurable difference. Moreover, even when falls prevention guidelines are put in place, they can create unintended negative consequences — for example, fear among nurses that a fall might occur can cause increased stress and strain, which over time leads to burnout, declining job satisfaction, and higher nurse turnover rates (King et al., 2018).

This problem of unintended consequences is also noted by Growdon, Shorr, and Inouye (2017), who point out that falls prevention programs can create tension between nurses who want to encourage patient mobility and nurses who prefer that patients remain stationary to avoid a fall. The study by Growdon et al. (2017) should be considered alongside King et al. (2018) because both highlight risks associated with implementing a falls prevention program — risks that most other studies overlook. For instance, Wilson et al. (2016) do not address this issue at all, focusing exclusively on the positive aspects of a falls prevention program.

In summary, the literature reveals several important points. First, falls prevention programs tend to focus on helping patients become more agile through exercise and balance techniques (Fu et al., 2015; Lim et al., 2017). Second, falls prevention programs can be effective in reducing falls (Khalifa, 2019). However, prevention can come at significant cost or risk, as Growdon et al. (2017) and King et al. (2018) demonstrate. Falls prevention strategies can help nurses reduce the number of falls in a unit — and that evidence has been empirically supported — but those strategies can also create tension and increase stress for nursing staff. This is a complex issue that must be carefully considered before an appropriate solution can be designed and implemented.

Discussion of Fall Prevention Strategies

The objectives of a falls reduction plan should include: (1) analyzing current fall prevention practices in the hospital; (2) identifying high-risk patients and verifying that fall prevention strategies are in place during shift change and handoff report; (3) identifying the challenges to fall prevention on the unit; (4) reducing falls by ensuring that call lights are answered promptly, even if the patient is not one's own; (5) practicing "No Pass Zone" etiquette — answering call lights without bypassing them, regardless of patient assignment; and (6) monitoring fall rates and evaluating the implementation of prevention practices. These recommendations are consistent with the findings of researchers such as Wilson et al. (2016) and Khalifa (2019). When nurses implement these strategies, they can reduce the number of falls in the unit.

However, additional steps must be included in order to mitigate the risks identified by Growdon et al. (2017) and King et al. (2018) — namely, the creation of tension among nurses and an increase in stress and fear. First, nurses should be clear on which patients are at high risk for falls and which are not. Second, they should collaborate and communicate effectively so that everyone understands which patients are working toward increased mobility and may need extra support, and which patients require less intensive attention. Above all, guidelines should reinforce that a nursing unit operates as a team, and that it is never acceptable for team members to blame one another when a negative outcome such as a fall occurs. Falls will happen. The goal is to reduce their frequency — not to eliminate them entirely, which is an unrealistic standard. Nurses should therefore accept that some degree of risk is inherent in any prevention program, and no approach will be perfect. Effective communication and collaboration can be instrumental in reducing interprofessional tension, particularly when there are differences of opinion about which patients should be mobile and which should remain stationary.

As Wilson et al. (2016) found, the foundation of a successful falls prevention approach is to tailor the plan to the specific needs of the unit. This means the program does not have to follow a one-size-fits-all model. What works in one study environment may not work in another because every environment is different — each unit has a unique workplace culture, a unique nursing team, and a unique patient population. By assessing what resources are available and understanding the needs and concerns of all stakeholders, a meaningful falls reduction plan can be developed and implemented. As King et al. (2018) emphasize, the plan must not generate undue stress. Nurses need to feel supported, not scrutinized or threatened. They should feel encouraged rather than fearful of failing to meet a goal. This is where effective leadership becomes essential — ensuring that nurses are motivated by a spirit of good will rather than by fear of punitive consequences.

With that in mind, the planned steps for implementing a falls reduction policy should include: (1) interviewing staff on the unit to understand current best practices and identify what works best in their specific context; (2) conducting daily audits to verify that fall prevention strategies are consistently in place; (3) complying with patient safety standards by maintaining checklists for both day shift and night shift, thereby ensuring a safe environment; and (4) researching how effective communication can support falls prevention efforts across the nursing team. These are best practices drawn from the research literature, and they collectively demonstrate that preparation is the most effective form of prevention. In the field of nursing, it cannot be assumed that common sense alone constitutes a strategy or can substitute for formal policy. The best prevention approach is to have a falls prevention policy in place — while simultaneously taking care to reduce the risk of unintended consequences such as burnout and stress.

The first step — interviewing staff — serves to understand what nurses recognize as best practices and to compare those perceptions with the strategies identified in the literature by Khalifa (2019). It is also important to remember, as Wilson et al. (2016) note, that the best plan is the one that fits the unit. Adaptation is therefore essential. The unit leader must learn what will work for the nursing team and what will ask too much of them. If the mental health of the team is adversely affected, the health and safety of patients will inevitably suffer as well. Feedback gathered during interviews should inform a policy plan that does not overburden nursing staff. The goal — reducing falls — must be kept realistic. Leaders should avoid implementing an idealistic policy that will only stress nurses and damage morale.

The second step involves monitoring the plan to determine whether it is working or whether adjustments are needed. Conducting daily audits is one method the literature recommends, as they can keep staff focused on the mission and mindful of their responsibilities. However, daily audits can be time-consuming, and nurses who are already busy may feel that too much is being demanded of them. A conversation should be held with the nursing team to assess whether daily auditing is feasible without adding undue burden. If nurses feel it would be excessive, the leader should identify an alternative — such as shift-based checklists for both day and night staff — as a more manageable substitute.

The third step is compliance with patient safety standards. Checklists are one practical tool for achieving this, and if nurses are receptive to the approach, it can help sustain momentum as the change is implemented. Maintaining progress during any organizational change requires consistent reinforcement. A safe environment must remain a priority, but never at the expense of nurses' mental health. Leaders should adopt a servant leadership style, modeling the behavior they wish to see. When leaders consistently demonstrate "No Pass Zone" etiquette and proactive patient support, that standard gradually becomes embedded in the unit's culture and eventually feels natural to staff.

The fourth step involves researching how to communicate and collaborate effectively. Nurses rely on communication and collaboration to maintain continuity of care. When communication breaks down, patient safety risks increase and workplace morale can decline, leading to resentment among staff. Nurses must therefore understand that communication is not merely a professional courtesy but a patient safety imperative. The most effective way to sustain communication and collaboration is to cultivate a culture that actively supports them.

Conclusion

Reducing falls in a surgical step down unit is possible, as demonstrated by 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 must also be mindful of the risks to their own mental health and well-being that can arise if expectations exceed what the team can reasonably sustain.

If a unit is unable to address falls reduction without sacrificing the mental health of its nursing staff, the leader must return to the drawing board. Whether the underlying challenge involves communication, insufficient time for daily audits alongside other clinical responsibilities, or a culture that does not yet support the program, the leader must continuously monitor the situation as the plan is implemented and maintain a clear sense of what is working and what is not.

There is no one-size-fits-all solution, and leaders should accept that plans must be tailored to the needs of the unit. If opportunities exist to incorporate exercise and balance training on the unit, that is one option to explore. If tools for increased digital monitoring and telehealth technology are available to reduce falls remotely, that is another avenue to consider. The essential point is that what works in one unit — or in one study — will not necessarily translate to another unit. Adaptability, ongoing communication, and sustained leadership engagement are the cornerstones of any effective falls reduction effort.

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.