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Running head: FALL PREVENTION IN INPATIENT MED-SURG. UNIT
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Fall Prevention in Inpatient Medical Surgical Unit
Falling is one of the significant challenges facing the healthcare system having sequelae
ranging from abrasions and minor bruises to more complex and severe outcomes such as
fractures and lacerations. In recent years, there has been an increase in the age-adjusted fall
mortality rates. The Centers for Medicare and Medicaid Services (CMMS) has included all the
complications as a result of fall during hospitalization among the non-reimbursable events.
Statistics show that US hospitals record more than one million cases of patient fall per annum
which accounts for 85% of the total hospital-acquired conditions. There are variations in
inpatient fall according to the characteristics of each unit. However, medical-surgical patients
have the highest risk compared to other patients. According to Williams et al. (2014), the USA
Medical-surgical units registered between 3.67 and 6.26 falls for a thousand patients each day.
20% of these falls cause injuries and 2% result to severe injuries. Patients under acute care have
a high risk of falling due to different factors such as medication side effects, alteration of
mobility, and previous history of falls among others.
PICOT Research Question
As a nurse on a medical-surgical unit, I have realized that sitters are only assigned to
patients after they fall. Why is the fall not prevented before it happens? To find the answer to
this, a question needs to be generated by using the PICOT format. The research question is: In a
high risk fall patient on a Medical-Surgical unit, how does assigning staff to sit with patients
around the clock compared to hourly rounding prevent falls in the period of their hospitalization?
Medical-Surgical unit staff will rotate hourly to sit with patients who have been assessed to be
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high risk of falls. This research will not cost the hospital financially, since the staff on schedule
will be the same staff rotating to sit with these patients.
Current Evidence-Based Practice
Different evidence-based research outlines the increased risk of fall of the medicalsurgical unit patients. For instance, Cuttler et al. (2017) discussed how to reduce medicalsurgical inpatient falls and injuries through the use of alarms, icons, and videos. Increasing
patient education and continuous application of bed exit alarms decrease the number of fall
injuries at a great extent. Also, Graham (2012) examined the current evidence-based
interventions for the reduction of the number of inpatient falls. The results revealed that some of
the strategies to adopt for preventing these falls include the use of environmental aids, the
management of medication, fall alarms, and video monitoring among others.
Stakeholders
Some of the critical stakeholders include residency directors that are responsible for the
interpretation of the outcomes obtained from the staff fall prevention and assessment of
knowledge as well as the development of the educational strategy. Other parties interested in the
enhancement of fall reduction program include fall team leaders that monitors the application of
fall prevention measures to ensure there is a reduction in the number of falls. The acute care
nurse managers are responsible for not only enforcing interventions adopted by interdisciplinary
teams but also ascertaining that such interventions become standard of care to the patients that
are at high risk of falling. There is a need for all the disciplines to incorporate information on fall
and prevention of injuries in their discharge plans.
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Costs related to Patient Falls
Since Centers for Medicare and Medicaid Services (CMMS) classifies patient falls under
the non-reimbursable events, the patient has to incur an increased cost for the treatment of the
injuries that occurred during hospitalization. Patients experiencing in-hospital falls stay longer in
hospitals which has a direct association with higher costs and amounts to an increase in the cost
incurred by the health institutions. The hospital can also incur costs related to putting in place
strategies aimed at prevention of patient falls in medical, surgical unit. Lawsuits filed by patients
and family members could also result in increased compensation costs by healthcare providers
due to their negligence (Akinwotu, 2017).
Ethical and Legal Issues
Nurses are required to provide quality services to all patients, but there are increased
shortages of nursing. Prevention of patient fall involves the provision of patient-centered care.
Healthcare professionals find it challenging to balance care quality and efficiency. There are
negligence legal issues related to falls prevention in adult inpatient surgical units. Healthcare
practitioners have to exercise diligence and due care when caring for patients in the hospital to
prevent injuries.
Conclusion
The patient is usually not in the hospital because of falls, so attention is naturally directed
elsewhere. Yet a fall in a sick patient can be disastrous and prolong recovery process. Sustaining
the strategy of sitting with patients to prevent falls might be a challenge, but seeing the results
and benefits will encourage the staff to continue with the process.
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Literature Review
The basic definition of nursing is caring for patient with different conditions. Therefore,
the capstone project relates to Jean Watson’s Caring Science theory (Clark, 2016). The focus of
this approach is on helping people in embracing the positive energy flowing through the
integrated body, spirit, and mind and that it has a mutual benefit to both the nurse and the
patients. Nurses play a key role in putting the patient in best position that promotes self-healing.
Through active engagement in caring by intentionality and authentic presence, nurses facilitate
the optimization of the patient’s ability to heal from within (Durant et al., 2015). According to
Jean Watson, caring is responsible for the regeneration of the life energies as well as potentiating
our capabilities that promote self-actualization both professionally and at personal level. Selfhealing is a critical process in the rejuvenation of personal energy reserves and replenishment of
the spiritual bank (Warber et al., 2015).
The theory of human caring components includes the basic carative factors, the
modalities of healing, transpersonal caring relationship, and the process of caritas. The carative
factors refer to the desired features that a professional nurse needs for the establishment of
therapeutic relationship and promotion of healing. The carative factors are the basis for
understanding nursing as the science of care and aiding patients towards their recovery (Yeter,
2015). Preventing the number of falls in high risk fall patients requires that both nurses and
patients should be aware of the best practices that facilitate healing as outlined by the carative
factors (Vonnes & Wolf, 2017). Developing a positive patient perception of the nursing activities
promotes positive relationship between the nurse and patient and is the basis for definition of
care. These factors could be essential in designing fall prevention programs in the hospitals
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based on the individual needs. Through carative process, nurses are able to provide spiritual and
loving care around the clock that reduces fall in acute care settings (Pajnkihar et al., 2017).
The transpersonal caring relationship is responsible for the creation of energetic
environment of both the nurses and patients which results to optimal care and healing that
reduces the number of patient fall (Anderson et al., 2017). In such situation staff siting with
patients around the clock are aware of their duties and responsibilities emanating from heart.
Transpersonal caring relationship relates to prevention of fall by defining the care provided by
the staff sitting with patients around the clock. The caring or healing modalities refer to practices
that enhance the ability of engaging in career moments and transpersonal relationship (Norman
et al., 2016). This component relates to the project capstone since it refers to exercises such as
centering, attention to touch, and communicating specific knowledge which are essential in the
prevention of incidences of falls.
There are various empirical studies on this subject that provides different knowledge on
the prevention of falls amongst the high risks fall patients. For instance, Cumbler et al. (2013)
found out that even though intervention is essential in case of occurrence of any problem,
effecting real change requires undertaking of a quality improvement initiative such as placing
nurses to sit with the patients around the clock. Patients that exhibit alterations in the mental
status have higher risks of falling. The provision of a physical sitter is one of the most common
used strategies for prevention of falls with injury for the population (Lilley et al., 2014). A
physical sitter is responsible for the provision of continuous patient surveillance hence the ability
of redirecting forgetful patients when need arises as well as assisting the patients physically to
prevent falls (Uhrenfeldt & Høybye, 2015). McCurley & Pittman, (2014) in their study found out
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that increase in the continuous surveillance hours per patient prevents the occurrence of patient
falls associated with physical sitters. The study proposed that there is need to include prevention
of falls with injury in the financial return projections. Therefore, future researches should focus
on collection of more data to account for these projections.
Also, Huang et al. (2014) found out that there was increased knowledge and self-efficacy
of preventing fall among patients with advanced cancer after the Fall Prevention Participatory
Program (FPPP) intervention. Patients are likely to display better understanding and concerns
about falls hence a reduction in the number of falls in the hospital due to the intervention.
Furthermore, it is evident that bedside is one of the most frequent location for falling in the
healthcare institution (Watson et al., 2015). Therefore, designing an effective education
intervention strategy could improve the knowledge of patients and quality of care. The study
recommended that future studies should use rigorous design in confirming the impact of FPPP on
reduction of fall cases in hospitals.
A regional study that uses larger sample size would give an opportunity for assessing the
self-efficacy of patient in the prevention of fall. Hempel et al. (2013) documented the
implementation, adherence, and effectiveness of the available approaches of preventing fall
among the acute care patients. Even though there are promising approaches, the establishment of
the evidence for the prevention of falls requires implementation and better reporting outcome.
The study proposed that there is need to include better reporting of outcomes for establishment
of a strong evidence base for reducing falls in health institution.
Research Methodological Approach
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The study will adopt the use of components of the mixed method that includes a
combination of both the qualitative and quantitative research design in collecting and analyzing
data. The researcher will obtain statistical data from the current trends, whereas, the population
of the study will help in the collection of subjective data. The use of a mixed method is essential
since it will increase the understanding of fall event context and prevention strategies compared
to when using quantitative data alone. Using this approach, the researcher will start with the
collection and analysis of quantitative data before collecting qualitative data. Combining both
findings provides a detailed interpretation of the results. Therefore, mixed methods will give a
broader overview of the subject under study.
Alignment of the Approach to Research Problem
The use of a mixed method will help in outlining not only the ineffective interventions
but also the necessary additions for improving the manner in which to address the problem. In
this case, it will show the impact of placing staff to sit around the clock with patients at high risk
of fall on the reduction of fall rates. This approach aims to enable managers in healthcare
institutions to use cost-benefit analysis in the determination of the efficacy of the added
intervention in the efforts of reducing falls. Findings from the mixed method research design will
help in the identification of both barriers and facilitators to implementing the placement of staff
to sit with high-risk fall patients around the clock.
Data Collection Method
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The study will adopt the use of the survey as the data collection tool. The anonymity of
the respondents is likely to increase the provision of honest answers hence accurate data. The
study will select a convenient sample of nurses to participate in the research. This data collection
tool will aim at addressing issues related to the respondents’ opinion on whether placing
healthcare professionals to sit with high-risk fall patients around the clock is a useful program in
the prevention of hospital fall. It will also cover the necessary improvements required to ensure a
reduction in the number of hospital falls. The healthcare professionals participating in the survey
had experience in dealing with patients that have a high risk of fall.
Data Analysis
The study will use statistical analysis by analyzing the number of falls within an
identified period. The review aims at differentiating between patients that are at high risk of
falling and those at low risk. It will measure sensitivity which refers to the percentage of the
people that fell within a given period as predicted hence identified as high risk. The specificity
test will determine the rate of patients not predicted to fall and did not fall thus identified low
risk. The Positive Predictive Value (PPV) will measure the possibility of a patient falling after
testing positive for the threat to falling. However, the Negative Predictive Value (NPV) will
indicate the percentage of the patients proving negative for the risk to fall is unlikely to fall
(Walsh et al., 2010).
Background and a Rationale for Methodologies
The reason for increased falls in the medical, surgical unit is the reduced sum of nursing
hours for each client in a day as well as a low percentage of registered nurse hours for the
medical, surgical units. In the study, it was evident that during October alone there were ten falls
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in the surgical unit. The repeated falls were excluded from the primary analysis. The study also
grouped the number of falls as assisted or unassisted and did not consider the unclassified
number of falls. Majority of the falls in the surgical units were least likely to be classified as
unassisted. In the medical, surgical unit, the registered nurse staffing does not predict increased
unassisted fall rate (Staggs & Dunton, 2013).
The justification for Subject Selection and Sampling Procedure
Although there are variations in the inpatient falls depending on the unit characteristics,
the patients in the medical-surgical units are at higher risks compared to those in intensive care
units (ICUs). According to Williams et al. (2014), the US medical-surgical units indicate around
3.67 to 6.26 number of falls per 1000 patient days. 20% of such falls causes some injury while
2% could cause severe injuries. These statistics show the need of developing effective strategies
to reduce the number of falls in the surgical units which will account for the reduction in the
recorded hospital falls to a great extent. Patients in the surgical groups are at high risk of falling
because of the alteration of mobility, adverse effects of medication, frequency in toileting, and a
shift in the mental status of the patients.
Limitation of the Study
Some of the limitations inherent to this study include the focus on one healthcare
institution hence making it difficult to generalize the findings to other hospitals in the healthcare
industry in general. Therefore, there is a need for future studies in different healthcare
institutions before the adoption of the proposed processes.
Implementation Plan
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The study recommends the use of Lippitt's change theory in implementing the placement
of nurses and CNA’s to sit with patients around the clock intervention for prevention of falls in
high-risk fall patients. It will provide the required framework for implement change. The first
phase includes the assessment of the patient by the nurse to record information that provides for
clinical history, medical observation, and background data among others (Mitchell, 2013). This
step will form the fundamental part of the nursing process. The second element is planning that
involves the collaboration of the nurse with other relevant stakeholders for the determination of
the needs of the patient. It will help in the identification of activities essential in the protection of
patients from harm since there is a need for balancing fall prevention with other priorities.
Thirdly, the implementation phase will include nursing staff sitting with patients round the clock
while documenting the results. Lastly, the evaluation will provide an opportunity for continuous
assessment of the needs of patients which are significant or not crucial during the care period.
When implementing the intervention, action planning will provide detailed systematic
steps to consider in reducing the number of falls among the inpatient medical, surgical units. The
purpose of using this implementation tool is for clarification of the required resources for the
achievement of this goal and formulation of a timeline for achieving specific targets (Reynolds &
Sutherland, 2013). The use of a well-developed action plan will help the physician in developing
SMART goals that the nurse should achieve. The action plan will not only include the gathered
information but also brainstorm the nurses on the objectives and strategies of reducing the
number of falls among high-risk patients. The process will require the involvement of all the
staff on the unit.
The process for implementation will start with the definition of the goal of placing nurses
and nurse assistants to sit around patients by ensuring that it aligns with the overall business
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objectives. Secondly, it will measure the success or failure of this fall prevention strategy
through identification of tactics related to the goal. Also, it will include the identification of the
point that requires optimization. The third stage will be the determination of the possibility of
attaining the set goals. It will consist of identification of strategies to put in place to reduce the
number of falls recorded in the surgical units. There is a need to analyze whether the healthcare
institution has the adequate resources or not to identify any gaps to fill. Lastly, developing an
appropriate timescale will not only prevent alienation but also promote the likelihood of success.
The goal is to maintain urgency and focus as well as clarifying the timeline for achievement of
the objective.
In evaluating the success of the adopted fall prevention strategy, the study recommends
the use of reduction in the number of falls as the primary measure of outcome. A decrease in the
number of falls in the surgical unit could indicate the effectiveness of the adopted strategies
while an increase could prove the need for improvement. Another outcome variable is the fall
risk. It includes the assessment of the number of patients that are still at risk of falls after the
implementation of the prevention approach (Coote et al., 2014). A reducing trend in the number
of patients in the surgical units at high risk of fall shows positive outcome measure. Furthermore,
recording the number of falls over a given period outcome measure will indicate the success or
failure of this method. The last measure is recording the number of dangerous falls that have
severe effects on the patients. It will include identification of the number of fall in the surgical
unit that results into injuries and those that are minor.
Although the study expects the results to be gradual, the estimation is that there should be
a reduction in the number of falls by the first month after implementation of this approach.
Nurses can watch the patients around the clock hence providing assistance and guidance. For
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example, when a patient from the surgical unit tries to walk, the nurse may guide him through
the process by helping him out. However, eliminating the repetitive falls will take time since the
study forecast that patients will need more time to adjust to their physical structures. Thus, it may
take three months or more to realize the benefits of reduced fall as a result of the placement of
nurses to sit around the clock to patients at high risk of fall.
The implementation of this strategy involved the collaboration of multiple health care
practitioners to achieve the desired outcome. For example, during the stay of patients in the
surgical unit, they interact with different professionals such as nurses, physicians, and
technicians among others. Therefore, collaboration was critical in the implantation of this
approach for achieving diverse opinion on the reduction of falls through the placement of nurses
to sit around the clock on patients at high risk of fall (Barton, 2009). Communication among
stakeholders involved outlining of the critical information for the assessment of patient needs.
For example, nurses had to communicate with the physicians to determine the symptoms of the
patients that place them under higher risk of falling.
Evaluation Plan
The estimation is that the program should reduce the number of falls in the surgical unit
recorded over a specific period. When evaluating this outcome, the study will base on the basic
principle of quality measurement that argues that the inability to measure makes it challenging to
improve it. Hence, when evaluating the success of the proposed prevention program, there is a
need to count and track the number of falls recorded after placing nurses to sit with high-risk
patients around the clock. By determining the number of falls, the nurse will be able to determine
whether the care is improving or has no impact on patients in the Med-Surg. Unit. When
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measuring the number of falls, it is essential to consider a measure that is comparable over time
within the Med-Surg. Unit to determine any improvement in care. Therefore, the study will
calculate the number of falls as a rate per given number of patients. A reduction in the rate of
falls shows the effectiveness of the program.
The study will measure the number of patients that are still at high risk of fall due to
either intrinsic or extrinsic factors despite the placement of nurses to sit with them around the
clock using the fall risk outcome. The estimation is that when nurses sit with high-risk patients,
they should reduce the number of falls due to extrinsic factors. The provision of nursing
assistance services should reduce the relative risk for various risk factors (Coote et al., 2014).
Due to the variations in the risk factors across the units in the healthcare institution, the risk
factor assessment will be tailored to the Med-Surg. Unit. A reduction in the number of falls will
show that the nurses are successfully addressing all risk factors identified in their care plans. A
reduction in the number of fall-related injuries shows an increase in patient safety in the MedSurg. Unit. Fall injuries result in increased hospitalization hence increased cost. When measuring
the effectiveness of the proposed strategy, a lower average hospital cost for fall injury indicates a
reduction in the number of falls that causes fatal accidents. Measuring the percentage falls that
causes injuries will determine whether nurses have an impact on reducing injurious falls. The
frequency outcome measure will show the patients at risk of experiencing repetitive falls.
Assessing the likelihood that a client will fall after a given period will help in the management of
the condition. When measuring the success of this outcome, it is essential to consider the role of
nurses in predicting the next fall episode and taking corrective measures to reduce injuries
(Watson et al., 2015).
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The challenges inherent in placing nurses to sit with high-risk patients around the clock
are mainly associated with the care providers and the context that the practice will occur. That is,
when the nurses have limited information on the purpose and aim of the program, it may fail to
achieve the intended outcome. Inadequate knowledge on evidence-based practices among the
caregivers could act as a hindrance to the successful implementation of the plan. They may not
be motivated to perform effectively hence the inability of providing patient-centered services
(Koh et al., 2008). Therefore, effective implementation could require adequate knowledge and
attitudes among nurses placed to sit with the patients at high risk of fall. It may be difficult in
future to ensure that all the staff members are motivated to perform better.
There are increased shortages of nurses in the healthcare system. Placing a nurse to sit
with high-risk patients around the clock could impact on the operation and efficiency of other
departments. In future, the healthcare institutions could find it difficult to maintain this program
as it takes the majority of the nurses’ time hence limiting them to provide services in other areas.
It may cause additional costs that could be costly for the hospital to sustain in the long run.
Furthermore, managers could find it difficult to reconcile the characteristics of the patient such
as the ethnic group and health status with the proposals which could hinder the success of this
program in future. The diversity and multi-racial patients could be challenging to nurses during
the plan implementation. For instance, it could limit communication due to language barriers
hence nurses could find it difficult to inform the patients on the risks associated with fall.
Some of the opportunities of placing nurse to sit with high-risk patients include a
reduction in the hospital costs related to falls. It will reduce the number of patients’ falls hence
the hospitals will incur less cost to cover falls that occur in the health institution. Moreover, it
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will enhance the provision of patient-centered care by considering the needs of patients in the
care provided thus improving their competitive advantage in the long run. Also, it will reduce
legal actions against the hospital due to in-patient falls. It will create a positive reputation and
goodwill that will increase the market share.
Dissemination Plan
Over the past years, the number of patient falls has been on the increase in the majority of
the healthcare institutions. Placing nurses to sit round the clock with patients at high risk of
falling could prevent the number of falls recorded in the hospital. The responsibility of the nurses
will be assessing the fall risk level of all patients to determine the riskiest during admission. The
estimation is that placing patients to sit around patients at high risk of falling will not only
prevent falls but also save some money. The stakeholders and end users will include RNs,
clinicians, and Certified Nurse Assistants (CNAs) among others who can use the findings in
initiating action that addresses the prevention of falls in a hospital. Physicians and other clinical
officers can utilize this strategy in the surgical units to reduce the hospitalization period of
patients due to injuries from falls.
The first step will involve an assessment of the risk level of patients as soon as they are
admitted to the hospital. After determining that the patient is at high risk of falling, the head
nurse will make a roaster of the registered nurses and CNAs that will sit with the patients. They
will take hourly turns, and they can utilize the time spent with the patient chatting as well as
catching up on their documentation. The healthcare providers will have to sit with the patient
throughout their period of stay in the hospital. To accomplish this goal, physicians should
collaborate with the RNs and give any relevant information about the patient that could be useful
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in the reduction of fall rates. It is also necessary to involve all the members of the surgical unit
and managers.
The dissemination of this strategy will be through the use of posters and oral presentation
of the duties of the nurses sitting around the clock with patients at high risk of fall. The duty
roasters will be displayed on the notice board in the unit. Evaluation of the functionality of this
approach will include keeping track of the number of recorded patient’s falls after the placement
of nurses to sit with high-risk patients. It will also include measuring the number of falls that
cause fatal injuries. It will also include determination of the likelihood of a patient falling after a
specific time.
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