The Gerontologist

cite as: Gerontologist, 2018, Vol. 58, No. 2, 331–340

doi:10.1093/geront/gnw156
Advance Access publication 23 December 2016

Research Article

Impact of Fall Prevention on Nurses and Care of Fall Risk

Patients

Downloaded from https://academic.oup.com/gerontologist/article/58/2/331/2736326 by guest on 18 March 2024

Barbara King, PhD, APRN-BC,1,* Kristen Pecanac, PhD, RN,1 Anna Krupp, RN, PhD(c),1
Daniel Liebzeit, RN, BS,1 and Jane Mahoney, MD, MS2
School of Nursing, University of Wisconsin-Madison. 2Division of Geriatrics, School of Medicine and Public Health,
1

University of Wisconsin-Madison.
*Address correspondence to Barbara King, PhD, APRN-BC, School of Nursing, University of Wisconsin-Madison, 701 Highland Avenue, Madison,
WI 53705. E-mail: [email protected]

Received June 11, 2016; Accepted July 11, 2016

Decision Editor: Barbara J. Bowers, PhD

Abstract
Purpose of the Study: Falls are common events for hospitalized older adults, resulting in negative outcomes both for
patients and hospitals. The Center for Medicare and Medicaid (CMS) has placed pressure on hospital administrators by
identifying falls as a “never event”, resulting in a zero falls goal for many hospitals. Staff nurses are responsible for provid-
ing direct care to patients and for meeting the hospital no falls goal. Little is known about the impact of “zero falls” on
nurses, patients and the organization.
Design and Methods: A qualitative study, using Grounded Dimensional Analysis (GDA) was conducted to explore nurses’
experiences with fall prevention in hospital settings and the impact of those experiences on how nurses provide care to fall
risk patients. Twenty-seven registered nurses and certified nursing assistants participated in in-depth interviews. Open, axial
and selective coding was used to analyze data. A conceptual model which illustrates the impact of intense messaging from
nursing administration to prevent patient falls on nurses, actions nurses take to address the message and the consequences
to nurses, older adult patients and to the organization was developed.
Results: Intense messaging from hospital administration to achieve zero falls resulted in nurses developing a fear of falls,
protecting self and unit, and restricting fall risk patients as a way to stop messages and meet the hospital goal.
Implications: Results of this study identify unintended consequences of fall prevention message on nurses and older adult
patients. Further research is needed understand how nurse care for fall risk patients.
Keywords: Falls, Hospital/ambulatory care, Nursing, Qualitative analysis: Grounded Theory

Falls in older adults are a major public health concern often patient fall rates (He, Dunton, & Staggs, 2012). However, falls
resulting in longstanding pain, functional impairment, dis- in hospitals commonly occur in adults older than 65 years
ability, premature nursing home admission, increased length (MacCulloch, Gardner, & Bonner, 2007). In hospitalized older
of stay in hospitals, and mortality (Inouye, Brown, & Tinetti, adults, falls have steadily increased over the past 3 decades
2009; Mahoney, 1998; Oliver, Hopper, & Seed, 2000). Patient with numbers projected to rise significantly due to substantial
falls in hospitals are common with rates varying from 3 to increases in the aging population (Wanless, 2006).
17.1 falls per 1,000 beds days (Halfon, Eggli, Van Melle, & The occurrence of patient falls has been identified by
Vagnair, 2001; Oliver et al., 2000). A longitudinal study using Centers for Medicare and Medicaid Services (CMS) as one
National Database of Nursing Quality Indicators (NDNQI) of eight “never events” for hospital settings. Never events
data collected from 2004 to 2009 found a decrease in overall are high-cost, high-volume events that could be reasonably

© The Author(s) 2016. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. 331
For permissions, please e-mail: [email protected].
332 The Gerontologist, 2018, Vol. 58, No. 2

prevented by the application of evidence-based guidelines 2013 and completed on December, 2014. GDA, a variant of
(Rosenthal, 2007; Waters et al., 2015). A recent impact Grounded Theory (Bowers & Schatzman, 2009), was used
assessment, however, found that the CMS policy has had to explore acute care nurses’ experiences with fall prevention
no effect on the rates of injurious falls, perhaps because and how those experiences influenced care of older adult fall
there are no evidence-based practice guidelines for fall pre- risk patients. Similar to Grounded Theory, GDA is informed
vention (Waters et al., 2015), and few intervention studies by symbolic interactionism which focuses on exploring how
have been conducted on fall prevention in hospital settings individuals assign meaning based on interactions with others
with minimal evidence to inform practice. Of those con- and actions taken based on those interpretations (Blumer,
ducted, results have been mixed. A 2012 Cochrane review 1998). GDA is particularly well suited to discovery in areas
(Cameron et al., 2012) found that multifactorial programs where little is known and the focus is on individuals’ under-
are effective for patients who have a longer length of stay, standings and perceptions. GDA uses a cyclic process for
but no recommendations could be made for any component sampling (open and theoretical), data collection, and analysis

Downloaded from https://academic.oup.com/gerontologist/article/58/2/331/2736326 by guest on 18 March 2024

of these programs. Other systematic reviews found that (open, axial, and selective; Strauss, 2008). Unlike Grounded
either there was no conclusive evidence that fall prevention Theory, open coding tends to continue longer during GDA
programs reduce the number of falls (Coussement et al., to avoid early narrowing of focus and premature closure.
2008) or that multifaceted interventions may have a mod- Maintaining open coding is strategically done to explore
est effect on falls, but not on fractures (Oliver et al., 2007). “what all is involved” (Schatzman, 1991). For this study,
In hospitals, patient falls have a multifactorial etiology that open coding was continued through the fifth interview. The
can be subdivided into three categories: (a) physiological antici- end result of a GDA study is the creation of a conceptual
pated (gait instability, fall history, and current risk for falls); (b) model which explains the interaction among the primary
physiological unanticipated (fainting); and (c) environmental components of a social process (Strauss, 2008).
(external hazards or equipment failure) (Oliver et al., 2000). In
addition, individual inpatient units have unique characteristics
related to type of patients, staffing ratios, model of care, envi- Setting
ronment, and equipment availability, which also affect patient Data were collected from two hospitals located in
fall rates (Oliver et al., 2000). Due to the complexity of falls Wisconsin. The study sites differed in the number of patient
in hospital settings, a one-size-fits-all approach to reducing or days for people older than 65 years and in bed capacity.
preventing patient falls may not be feasible. Site A bed capacity is 530 with a reported percentage of
Staff nurses may have the greatest impact on reducing patient bed days for adults older than 65 years of 34.3%.
patient falls. Due to their 24-hr presence, nurses have the Site B bed capacity is 81 beds with a reported percentage of
most consistent contact with patients and continually moni- patient bed days for adults older than 65 years of 54.4%.
tor for conditional changes. However, no research has been Both hospitals are designated as teaching hospitals and
conducted on how nurses approach fall prevention or the have a nurse to patient ratio of 1:4.
multiple strategies they use to reduce the risk or prevent falls
in older adult patients. When falls occur, nurses often become
the “second victim” expressing increased stress, anxiety, guilt, Recruiting
concern for liability, and self-doubt about the quality of care Several recruitment strategies were used, including announc-
they provide (Brians, Alexander, Grota, Chen, & Dumas, ing the study at unit meetings (staff meetings and unit council
1991). The American Nurses Association (1999) and the meetings), e-mail invitations, and flyers placed in nursing staff
National Quality Forum (2004) use patient falls as a nurs- mailboxes. In the early phase, recruitment was open to all
ing-sensitive quality indicator, placing the responsibility for members of the nursing staff who care for patients identified
patient falls directly on nursing staff. This blame, along with as fall risk on the participating units. Open sampling tech-
potential pressure from administration to reduce falls due to niques were used to uncover as many relevant categories and
CMS penalties may alter how nurses care for fall risk patients. dimensions as possible (Strauss, 2008). As categories were
The purpose of this Grounded Dimensional Analysis developed, theoretical sampling was used to ensure density of
(GDA) study was to explore nurses’ experiences with fall categories, capture variation in how nursing staff perceived
prevention in hospital settings and the impact of those and cared for fall risk patients, and further the development
experiences on how nurses provide care to fall risk patients. of a conceptual model (Strauss, 2008). For example, staff reg-
The model developed in this study illustrates the impact on istered nurses (RNs) who served in formal leadership roles
nurses of intense messaging from nursing administration to (charge nurse, care team leader, and representative on a falls
prevent falls and the consequences to older adult patients, committee) seemed to perceive fall risk patients differently
staff nurses, and the organization. than nurses in nonleadership roles and described promoting
patient mobility as a means of preventing falls, rather than
limiting patient mobility. The researcher actively sought out
Methods these RNs by asking nurse managers on inpatient units to
Before conducting the study, Institutional Review Board provide names of individuals who served in a leadership cap-
approval was obtained. The study was initiated on July, acity. Further, there was a noticeable difference between RNs
The Gerontologist, 2018, Vol. 58, No. 2 333

and certified nursing assistants (CNAs) in how they described systematically relate all categories to each other and to
their experiences with patient falls and how fall prevention finalize the conceptual model.
was implemented on their units. As RNs expressed feeling Several strategies were used to ensure rigor of the study.
more responsible and frustrated with increased additional Data were analyzed within a group experienced with GDA
work resulting from patient falls and were more descriptive who were skilled at identifying researcher imposed catego-
in how they restricted patient activity compared with CNAs, ries not grounded in the data, making it less likely that pre-
a methodological decision was made to increase recruitment conceived assumptions would be imposed. Memoing was
and sampling of RNs. Recruitment and sampling contin- used throughout to inform sampling, data collection, and
ued until saturation was reached, and fresh data no longer analysis; record analytic decisions; and provide a record of
revealed new theoretical insights or new properties of the cat- how decisional matrixes evolved to describe the relation-
egories (Charmaz, 2014). ship among categories. Member checking was used during
focused interviews. At the end of interviews, participants

Downloaded from https://academic.oup.com/gerontologist/article/58/2/331/2736326 by guest on 18 March 2024

were shown a decisional matrix which identified catego-
Sample ries and asked to provide feedback on missing properties
The sample consisted of 27 RNs and CNAs who were or dimensions and suggest any alternative explanations for
employed on a medical, surgical, or medical/surgical adult interactions among categories. Finally, each category and
inpatient unit and caring for patients aged 65 years and the relationships among categories were tested by locating
older. Site A sample consisted of 2 nurse managers, 1 clin- supportive quotes from multiple interviews (Strauss, 2008).
ical nurse specialist (CNS), 2 CNAs, and 11 RNs. Site B
sample consisted of 10 RNs and 1 charge nurse (manage-
ment). This study did not collect participant demographic Results
data. In a Grounded Theory study, deciding who to sample All participants stated that the goal within their institution
is based on the dimensions that are salient to the categories was “zero falls.” Falls were defined by staff nurses as any
that emerge from the data (Strauss, 2008). occurrence in which the patient descends to the floor. Many
nurses described frustration in this definition, because even
if a patient was intentionally lowered to the floor to pre-
Data Collection and Analysis vent injury, the event was counted against them. There was
In GDA, data collection and analysis occur iteratively. variation within and between institutions in the pressure
In-depth, one-on-one interviews (N = 22 participants) and nurses experienced related to meeting an institution’s goal.
a focus group (N = 5 participants) lasting approximately Nurses who worked on inpatient adult units with high fall
30–60 min were conducted. All interviews were held in a rates described experiencing intense pressure, in the form
private office and were audio recorded and transcribed ver- of frequent messages from nursing administration (senior-
batim. Unstructured open-ended questions were used ini- level and midlevel), to “get the number down.” The more
tially. For example, all participants were asked, “What is intense the message, the more they altered their nursing
it like for you to take care of an older adult patient who is care by restricting patient mobility—an upright, mobile
identified as a fall risk”? Based on the participant responses, patient is one who can fall. Conversely, nurses who worked
additional broad questions were asked to help identify all on inpatient adult units with low fall rates did not experi-
possible dimensions of participant experiences. Most par- ence similar pressures. These nurses engaged in behaviors
ticipants described fall risk patients as burdensome and to promote and encourage independent patient mobility
making them feel nervous when providing care during their regardless of whether the patient was identified as fall risk.
work shift. Focused questions were asked once initial cate- How nurses respond to fall prevention messages delivered
gories and dimensions had been labeled. For example, with by nursing administration is illustrated in Figure 1.
fear of falls category, focused questions included, “Some
nurses have described feeling like they would get into trou-
ble if their patient fell, have you experienced this? Can you Fall Message
describe for me your concerns about getting into trouble”? Participants consistently identified their units as being
Data were analyzed using open, axial, and selective cod- labeled either a high- or a low-fall unit. Nurses stated
ing (Strauss, 2008). Open coding involved a line-by-line that the label of high- or low-fall unit was communi-
analysis to break down the data into concepts. Similar con- cated to them by nursing administration. Being identified
cepts were grouped into categories. Axial coding involved as a high-fall unit occurred if the unit had more than 2
identifying properties and dimensions of categories answer- falls monthly, whereas low-fall units had occasional falls,
ing questions related to when, where, who, how, and with every 3–6 months. Intensity of the zero falls message was
what consequences (Strauss, 2008). Axial coding allowed related to how often the message was sent, who sent the
the researcher to describe nurses’ experience with caring message, and the message tone (positive or negative). The
for fall risk patients with great detail and provided link- tone delivered to high-fall units was often blame and shame
ages between categories. Selective coding was used to and targeted individual staff involved in patient falls. Such
334 The Gerontologist, 2018, Vol. 58, No. 2

units that a fall occurred); and public postings (number

Low
Fall Message Falls
of fall free days on each unit). Because of the intense fall
High reduction message, RNs on high-fall units stated they often
Falls
over identify fall risk patients leading to an overwhelming
Administrave Progressing list of patients for whom nurses felt they must take extra
Support
precautions to ensure falls did not occur on their shift.
Intense
RN Characteriscs
“On a unit like mine, we have a lot of people that are
Administraon Staff Nurse
always identified as fall risk. I think out of 28 people we
Messaging
have 25 high fall risk” (Interview 6).

Daily messages also occurred as posting of fall free days.

Fear of Falls The unit’s progress of how many days without having

Downloaded from https://academic.oup.com/gerontologist/article/58/2/331/2736326 by guest on 18 March 2024

Nursing and Unit
Consequences a patient fall is displayed to everyone on the unit (nurs-
Consequence

ing staff, other health care providers, patients, and family

Paent

Protecng
members), because it is posted in a prominent location next
to the nurses station. Even when the unit made good pro-
Restricng
gress by going multiple days without a fall, many nurses
described a sense of heightened anxiety around not want-
Figure 1. Acute care nurse perceptions of fall prevention.
ing to be the one who ended the “streak.” When a fall
messaging led nurses to develop a fear of falls and a need occurred, seeing a zero posted was interpreted by nurses as
to protect themselves and the unit from being labeled as failure and having to start all over again.
a bad unit. For nurses on high-fall units, the best way to “That zero is really awful to see, you have to start all
achieve the hospital goal and stop the message was to over again, you don’t want to see a zero” (Interview 5).
restrict patient mobility.
In contrast, the fall message was experienced differ- Weekly and monthly messages were delivered in meetings,
ently by nurses who worked on low-fall units. For these such as monthly unit staff meetings, monthly unit coun-
nurses, the message was positive because they were meet- cil meetings (attended by a staff RN representative from
ing the hospital goal. When falls did occur, nurses on low- various inpatient units), and weekly nursing leadership
fall units did not describe feeling blamed or shamed, but meetings (between midlevel and senior nursing adminis-
rather stated the focus was on identifying problems within tration), or in the monthly hospital falls report e-mailed
the unit (environmental) or the patient (weakness) that may to all staff nurses and nurse administrators employed in
have contributed to the fall. Nurses on low-fall units did the organization. These messages compared unit to unit
not talk about protecting self and unit. Instead of restrict- success or failure in meeting the hospital goal, announced
ing patients, they described promoting patient ambulation when and where falls had occurred, and served as an add-
with the goal of progressing patients. itional source of pressure on high-fall units. Staff RNs from
high-fall units who participated in monthly meetings often
described feeling frustrated that their unit was identified as
Intense Messaging a “bad” unit.
Patient falls triggered a cascade of messages from a var- “When I go to unit council, I can see the scores and
iety of sources, senior nursing administration (chief nursing see that my unit is one of the higher units…other peo-
officer, director of inpatient services, and director of quality ple look at it and compare themselves…‘oh look at this
and safety), midlevel nursing administration (nurse man- unit’. It makes us feel bad” (Interview 10).
ager and CNS), and unit level (charge nurse) about why
falls continued to occur. Table 1 identifies the source of Monthly meetings that included only senior-level and
the message and the frequency of occurrence. On high-fall midlevel nursing administration often led to midlevel
units, the frequency of messages about falls was intense managers feeling blamed that their units were not meeting
and occurred on a daily, weekly, and monthly basis, as well the goal and could jeopardize the hospital Magnet status
as after every fall. The flow of messages occurred between designation.
senior-level and midlevel nurse administration, senior nurs- “And we met, there was a lot of push ‘falls aren’t okay’
ing administration to staff RNs on the unit, midlevel nurs-
and we met for about an hour and a half and it was
ing administration to staff RN, and staff RN to other RNs,
pretty negative. I remember it being painful” (Interview
and CNAs on the unit. Messages were delivered by several
1).
means, in person (shift report, post fall huddle, unit and
hospital wide meetings, and post fall investigation); phone Staff RNs also have to notify senior-level and midlevel
(to notify midlevel manager of fall); e-mail (to all hospital nursing administration every time a fall occurs. Staff RN
The Gerontologist, 2018, Vol. 58, No. 2 335

Table 1. Source of Messaging

Messaging Low-fall unit High-fall unit

Routine
 At the beginning of each shift, the charge nurse announces to all nursing staff which patients are at risk X
for falling
 Daily e-mail from senior administration to all nursing staff and administration about falls that have X
occurred
 Daily posting of number of “Fall free days” in a common space that is visible to everyone, including X
patients
 Weekly e-mail from senior administration to all nursing staff and midlevel administration about falls X
that have occurred

Downloaded from https://academic.oup.com/gerontologist/article/58/2/331/2736326 by guest on 18 March 2024

 Monthly discussion of patient falls during unit council meetings between midlevel administration and X X
nursing staff representatives
 Monthly discussion of patient falls during unit level meetings between midlevel administration and X
nursing staff
 Monthly discussion of patient falls during nursing leadership meetings between midlevel X X
administration and senior administration
Triggered by fall
Post fall huddle X
 Nurse documents fall in an error reporting system that is sent to midlevel administration and senior X X
administration
Nurse calls midlevel administrator post fall, anytime day/night X
E-mail from senior administration to midlevel administration about fall event X
Investigation about the fall event by midlevel administration X

notifications occur in the form of a patient safety net (PSN) Impact of Fall Message on Nursing Practice
report and an additional two-page explanation of the fall Due to the continual flow and intensity of messages related
event. Further, staff nurses on high-fall units must call the to patient falls, many nurses on high-fall units identified
unit manager (at any time of the day or week) to report that that they had developed a “fear of falls.” Nurses described
their patient fell and participate in a personal investigation fear of falls as concern for and the resulting reprimand if a
to determine what the nurse could have done differently to fall occurred; job security for themselves, unit manager, or
prevent the fall. This process of having to announce a fall CNS; and public exposure of their error to other nurses and
made nurses feel they were being scrutinized. hospital administration. Concern for reprimand seemed to
“They look at every aspect. They’re looking at your be related to the investigation that followed after a patient
charting. They’re looking were they on the fall risk, did fell. Nurses had to account in detail all that transpired
they have that wristband on and were you on top of it? before, during, and after the fall. This included details
I think people just feel like they’re under the microscope, about the patient, whether precautions (identifying patient
which they are” (Interview 9). as at risk for falls and placing a bed/chair alarm on the
patient) were in place, what happened immediately before
After every fall, the messaging intensified because the nurse the fall and during the fall, and what would have prevented
and the unit are perceived by administration as not doing the fall. Nurses often internalized the investigation as per-
enough to prevent patient falls. Nurses described increas- sonal and felt blamed for the fall event, frightened that they
ing intensity of the message as receiving more e-mails would get into trouble, and defeated.
from midlevel and senior-level nurse administrators about
patient falls, and increasing discussion about patient falls “She was tearing up, ‘I promise I set the bed exit alarm,
during shift report and unit staff meetings. Nurses on high- I promise, I promise’. Everyone is so afraid of getting
fall units stated that falls were always perceived as negative, into trouble” (Interview 3).
regardless of the circumstances, even when they were able
The overwhelming nature of fall investigations and the
to safely lower a patient to the ground to avoid injury.
intensity of messages to reduce falls left nurses concerned
“Somebody had a non-epileptic seizure…I lowered her that they would lose their job or their unit manager or CNS
to the ground…so that was a fall and ruined our score would be fired if falls continued to occur. The concern for
card…all I saw was a ceramic bathroom and a seizing job security was a common statement expressed by nurses,
patient…it should be like ‘good job’ but instead it was even though they could not identify anyone who had been
negative, negative, negative” (Interview 21). fired due to patient falls.
336 The Gerontologist, 2018, Vol. 58, No. 2

“I’m going to get fired…my unit’s going to be the one on predominant strategy used by nurses to protect the unit was
the bad list. Somebody from administration is going to to pressure all staff to urgently respond when a bed/chair
come down and we are going to get reamed out. All of alarm sounded. Nurses rationalized that if someone got to
a sudden somebody is going to be gone” (Interview 1). the patient “in time,” a fall would be prevented and their
unit numbers would continue to look good to administra-
Public exposure occurred when nurses had to announce
tion. The urgency to respond to alarms led to staff stopping
to the unit nursing staff, to other health care provid-
whatever they were doing and running to the source of the
ers (physicians and case managers) or to senior nursing
alarm. This often resulted in chaos on the unit with mul-
administration that their patient fell. Public announcement
tiple staff members running down the hallway at the same
occurred during post fall huddle, interdisciplinary rounds,
time. The need to run to alarms was reinforced among
and through e-mails sent to senior nursing administration.
nursing staff and came as a directive from nurse managers.
Announcements in the form of e-mails were also made to
The urgency to respond to alarms put even greater stress
the entire hospital. A post fall huddle involved gathering all

Downloaded from https://academic.oup.com/gerontologist/article/58/2/331/2736326 by guest on 18 March 2024

on nursing staff and increased their anxiety about caring
nursing staff members who were working during the shift,
for fall risk patients.
identify that a patient fell, discuss the causes of the fall,
and how the fall event could have been prevented. The post “Literally the CNS and nurse manager, they look at you
fall huddle was initiated by the nurse who was caring for and say, ‘I expect you to run into that room, I expect you
the patient who fell. Other times nurses had to announce to move faster’” (Interview 2).
during interdisciplinary rounds that their patient fell. As “You’re just running down the hallways… We’re all
with fall huddles, nurses had to recount to interdisciplinary scattered all over the place trying to run to these alarms”
health care providers all that transpired before, during, and (Interview 10).
after the fall.

“A nurse told me that she had to stand up in front of the Restricting

health care team, physicians, nurses, medical students,
To meet the hospital zero falls goal, nurses on high-fall units
and case manager, and tell them that her patient fell. It often altered how they provided care to fall risk patients by
was awful, she was traumatized” (Interview 18). restricting patient movement (containing patients or not
“If we had a fall it went hospital wide… it was embar- allowing ambulation) and privacy. The most efficient way
rassing. A lot of people felt that was shaming us or to prevent falls was to not allow fall risk patients to ambu-
blaming us” (Interview 21). late during their hospital stay. Most nurses described inten-
Ultimately, fear of falls resulted in nurses being fearful to tionally restricting patient ambulation as a primary strategy
care for fall risk patients. Fall risk patients were seen as a for fall prevention, even though they acknowledged that by
threat to nurses in terms of increased workload, blame, and doing so they could produce poor outcomes for patients in
continued flow of negative messages. Fear of falls resulted terms of loss of strength. For these nurses, the need to stop
in nurses altering their practice to protect themselves and intense messaging from nursing administration and meet
the unit. the hospital goal of zero falls superseded patient needs.

“People are really scared, we can’t have anybody fall,

we don’t walk our patients… and then when we do get
Protecting
them up they are weaker and we just shot ourselves in
Nurses primarily protected themselves from the increase in the foot” (Interview 21).
workload that occurred when the nurse had to notify mul-
tiple persons in administration that a fall happened, com- Nurses also restricted fall risk patient movement by con-
plete several pages of the incident report, call a post fall taining them. Containing patients was used as a strategy
huddle to discuss the event, and begin the fall investigation. when nurses wanted to get fall risk patients out of bed, but
The increase in time demands to notify, document, and were unable to provide constant surveillance as directed
investigate, interrupted the nurses’ workflow, putting them by nurse managers. Containing patients was done by pla-
even further behind in care duties for all of his/her patients. cing them in chairs they could not get out of or by placing
patients in chairs next to the nursing station where some-
“It increases workload when you have a fall and you one could continually tell them to not get up.
have to do all those things, the PSN, the phone, and the
huddle” (Interview 13). “When I want to get the patient up we use the naughty
“You’re already feeling bad that your patient fell. So chair, when you put them in it they can’t get out”
you’re going to get behind now with your work that (Interview 8).
already was out of control” (Interview 8).
Restricting patient privacy in the bathroom was also used
Nurses protected the unit from being identified as a as a strategy to prevent falls. The decision to restrict patient
“bad” unit by trying to keep the fall number down. One privacy came as a directive from nursing administration and
The Gerontologist, 2018, Vol. 58, No. 2 337

was based on number of falls that occurred in the patient sense of dread when they started their shift, felt defeated in
bathrooms. Nurses stated that patients often objected to their efforts, and described low job satisfaction.
their presence in bathrooms and asked the nurse to leave.
“I get very tired physically and mentally because it’s like
To get the patient to acquiesce, nurses’ pointed out signs
a roller coaster ride, you know, what’s happening next”
posted in bathrooms that indicated a nurse’s presence was
(Interview 7).
necessary for patient safety or appealed to the patient that
a fall would increase their work or that the nurse would get All nurses stated that a fall prevention protocol that tar-
into trouble. geted risk reduction for falls was not available on their
units. Rather, the three primary mechanisms communicated
“Sometimes I joke around…if you fall there’ll be a lot of
to nursing staff to reduce falls was to identify patients at
paperwork for me” (Interview 10).
risk, place bed/chair alarms on patients, and run to alarms.
Because nurses were not reducing risks for falls, their

Downloaded from https://academic.oup.com/gerontologist/article/58/2/331/2736326 by guest on 18 March 2024

Progressing efforts to meet the hospital goal (zero falls) were often not
In contrast, nurses on low-fall units focused on progressing successful, leaving nurses feeling defeated. In addition, as
rather than restricting patients. Progressing patients was nurses had few successes they often described poor job sat-
described by nurses who worked on low-fall units and by isfaction. Several nurses indicated that they were actively
some nurses on high-fall units who focused on the patient looking to transfer to a unit that had low falls.
and not the fall numbers. Nurses who engaged in progress- “It doesn’t feel good when you don’t get the award… it
ing patients did not describe fear of falls, need to protect self does chip at people. You know, well why don’t I go here
or unit, or restricting patients. Rather, these nurses focused and here. I’m going to try IMC nursing” (Interview 6).
on patient progression in terms of functional ability and
viewed ambulation as a means to maintain the patient’s
Consequences to the Unit
independence and discharge to home. Nurses progressed
The over identification of fall risk patients in tandem with
patients by maintaining physical strength and promoting
the “everybody runs” strategy to prevent falls, and the con-
safe mobility. Maintaining strength was achieved by getting
tinued messaging that the unit was not meeting the hos-
patients up and out of bed at least to a chair and walking
pital goal, produced low morale on high-fall units. The
early and often. Maintaining strength was seen as a neces-
“everybody runs” culture to prevent falls produced tension
sity for independence upon discharge and as a strategy to
between RNs and CNAs. Nurses described scolding nurs-
decrease risk for falls.
ing assistants or float staff if they did not move fast enough
“If you’re somebody who needs six walks, I don’t care or were not responding to bed/chair alarms. Criticism
if you’re a fall risk, we need to get in six walks to get in among nursing staff contributed to low morale.
your exercise” (Interview 15).
“You’re afraid of a fall happening so they you’re really
“The sooner they start, the more they’ll maintain their
hard on your NAs too because you’re like everybody’s
strength” (Interview 14).
got to run” (Interview 10).
Promoting safe mobility was a strategy to ensure patients
In addition, nurses described frustration in not being able to
walked and was achieved by using ambulation equipment
do the right thing for the patient (getting them up to walk)
(gait belt and walking device), gathering additional help
for fear that a fall would occur. Nurses believed if they did
(another RN or CNA), getting rid of tethers (intravenous
allow a fall risk patient to walk about independently they
lines and drains) that inhibited movement, or having some-
would be breaking a rule. Having their nursing judgment
one walk behind the patient with a wheelchair. Fall risk was
questioned further contributed to low morale on the unit.
not seen as a barrier to ambulation, but rather an indication
that additional support during ambulation may be needed. “It doesn’t make sense to me, we’re saying just while
you’re in the hospital it’s not okay to walk around, but we
“We need to get them up, the sooner they walk the bet-
feel safe enough to have you home by yourself? It makes
ter… making sure we have two people walking with
you a little angry at the person that’s telling you these are
them, using a gait belt and a walker” (Interview 14).
the rules. It’s a morale thing, it doesn’t matter what I do,
what my decision is, it’s going to be wrong” (Interview 13).
Consequences to Nurses and Organization
Consequences to the Nurse
Nurses on high-fall units described feeling overwhelmed by Conditions that Shifted Nurses to Progress
constant messages from nursing administration to prevent Fall Risk Patients
falls and the need to be on high alert to ensure that a fall did Two conditions were identified that influenced nurse deci-
not occur. This sense of feeling overwhelmed took a phys- sions to progress patients identified as fall risk. One con-
ical and emotional toll on nurses. Nurses often described a dition involved an external source, support from nursing
338 The Gerontologist, 2018, Vol. 58, No. 2

administration, whereas the other was an internal source, Menz, & Close, 2007) and are sometimes inevitable (Oliver
nurse characteristics. On several inpatient units, patient et al., 2000). Pressuring nurses to meet a zero falls goal may
ambulation was identified as a priority and encouraged have the unintended consequence of worsening functional
and rewarded by the nurse manager, even if the unit had status for older patients (Oliver, 2004). Zero falls rates
high fall rates. On these units, ambulating patients was the should be viewed with caution; a hospital unit with no falls,
standard of care used to improve patient outcomes. Nurses is a unit where patients do not move (Oliver et al., 2000).
were acknowledged for their efforts to get patients up to Nurses’ interviewed acknowledged negative conse-
walk by receiving individual recognition from unit lead- quences of restricting patient ambulation. However, the
ership (nurse managers, CNS, and charge nurses). When need to protect themselves and their unit overrode those
nurses on high-fall units felt supported by administration concerns. Restricting ambulation and/or enforced bed rest
they were more likely to ambulate fall risk patients. If a has long been recognized as contributing to muscle mass
fall did occur on these units, the focus of the investigation loss, postural hypotension, and a decrease in maximal work

Downloaded from https://academic.oup.com/gerontologist/article/58/2/331/2736326 by guest on 18 March 2024

was not on individual nurse, but rather included environ- capacity (Creditor, 1993; Kortebein, Ferrando, Lombeida,
mental and patient factors (weakness, low blood pressure, & Wolfe, 2007), all factors that increase an older person’s
and dizziness). Further, the fall investigation was used as fall risk (Mahoney, 1998). Many nurses engaged in behav-
a learning experience to improve how the unit could have iors that may actually increase fall rates both in hospital
prevented the fall. settings and when the patient goes home and to the next
point of care.
“I don’t feel the high impact from my manager, he’s
Nurses described three primary strategies used to pre-
always encouraging, keep ambulating and doing what
vent falls: (a) identify patients at risk; (b) place bed/chair
you are doing” (Interview 17).
alarms on patients; and (c) run to alarms. However, these
There were also nurse characteristics that prevented nurses strategies have been shown to be ineffective at preventing
who worked on high-fall units from developing a fear of or reducing falls. Identifying a patient as fall risk does not
falls. Nurse characteristics that seemed to have a protective provide an intervention to target the underlying risk factor
effect were being confident in clinical decision making, hav- (Oliver, 2007; Oliver, McMurdo, Daly, & Martin, 2004).
ing a formal (care team leader or charge nurse) or informal In addition, many fall risk identification tools are “home-
(seen as an expert on the unit) leadership role on the unit, grown,” and never tested for validity and reliability (Oliver,
and years of experience as a nurse. These nurses were not 2007). The ability to identify fallers and nonfallers can be
afraid of ambulating a fall risk patient because they cor- seriously jeopardized depending on the fall risk identifi-
rected the underlying cause that put the patient at risk for cation tool used. Identifying patients at risk may provide
falls (volume depletion, reducing tethers, and discontinuing nurses with false reassurance.
medications). In addition, they felt secure in their position Nurses also described dependency on bed/chair alarms
because they believed they were viewed as a valuable mem- to alert them when fall risk patients were moving and
ber of the inpatient unit. For these nurses, the focus was on were pressured by nursing administration to get to the
the patient and not the fall number. patient when the alarm sounded to prevent the fall. Mass
response created chaos on the unit and friction between
“If they’re orthostatic, they might need a couple liters of RNs and CNAs. Further, needing to respond to multiple
fluid before I’m going to get them up. After that we get alarms interrupted nurses’ workflow and increased work
up to walk” (Interview 2). demands for all unit staff. In reality, the use of bed/chair
alarms produced a negative consequence on nurses and
the unit, although this was not overtly recognized by the
Discussion participants.
Responsibility to prevent falls has been placed directly on The use of bed/chair alarms is controversial. Several
nursing staff in many hospital settings. Nurses feel increas- studies have demonstrated that these alarms are not effect-
ing pressure to meet the hospital goal of “zero falls” and ive in reducing fall rate or injurious falls (Shorr et al., 2012;
often feel blamed and shamed when falls occur. Findings Tideiksaar, Feiner, & Maby, 1993). Others have posited
from this study provide compelling evidence that nurses that bed/chair alarms are unethical in that they impair a
experience negative consequences when intense pressure is person’s autonomy for free movement, infringe on dignity,
placed on them to prevent falls. Consequently, many nurses and may worsen agitation in confused patients (Inouye,
adjust the care they deliver by restricting patient mobility, a Brown, & Tinetti, 2009; Oliver, 2007). Future research
strategy inconsistent with optimal patient progress. should address both the impact of bed/chair alarms on
In hospitalized older adults, falls are the result of inter- nursing workflow and how older adult patients experience
actions among complex factors including frailty, multiple being “alarmed.”
comorbid conditions, acute illness, unfamiliar environ- Although patients were not interviewed for this study,
ment, and medical/surgical procedures (Kannus, Seivenan, one has to wonder how older adults experience and per-
Palvanen, Jarvinen, & Parkkarri, 2005; Lord, Sherrington, ceive messages from nurses that they are at risk for falls
The Gerontologist, 2018, Vol. 58, No. 2 339

and the impact of restricted ambulation on the develop- the goal. This has resulted in unintended and potentially
ment of patient fear of falls. Fear of falls in older adults harmful consequences to nurses and older adult patients.
is associated with self-efficacy. Self-efficacy is influenced A strong evidence base for care delivery for fall risk patients
by receiving information about the ability to perform an is lacking. Additional research is needed to gain a better
activity (ambulation) from a credible and trustworthy understanding of how nurses (key health care providers in
source (nurses) and the actual performance of the activ- hospital settings) provide care to fall risk patients. There is a
ity (Bandura, 1982). Boltz, Resnick, Capezuti, and Shuluk need for patient centered and unit-based interventions that
(2014) demonstrated that fear of falls in hospitalized older prevent patient falls and also preserve patient function.
adults was associated with change in physical function
between admission to discharge. Limited ambulation dur-
ing hospitalization has been identified as an independent Funding
predictor of loss of physical function in hospitalized older
This work was supported by the Clinical and Translational Science

Downloaded from https://academic.oup.com/gerontologist/article/58/2/331/2736326 by guest on 18 March 2024

adults (Brown, Friedkin, & Inouye, 2004; Brown, Redden, Award (CTSA) program, through the NIH National Center for
Flood, & Allman, 2009). Therefore, being told throughout Advancing Translational Sciences (NCATS), grant UL1TR000427.
their hospital stay by nurses that they are at risk for falls The content is solely the responsibility of the authors and does not
had having ambulation restricted may be contributing fac- necessarily represent the official views of the NIH.
tors to development of fear of falls in hospitalized older
adults. Additional research on how hospital fall prevention
programs affect older adults needs to be conducted. Acknowledgments
Lastly, although falls have been identified as a nursing- This material is the result of work supported with resources and
sensitive quality indicator of patient care (National Quality the use of facilities at the William S. Middleton Memorial Veterans
Forum, 2004), there has been no empirical evidence on Administration Hospital. The contents do not represent the views
how nurses understood fall prevention and what actions of the U.S. Department of Veterans Affairs or the United States
they took to prevent patient falls. Prior intervention studies Government.
conducted on fall prevention in hospitals have shown lit-
tle impact on reducing fall and injuries (Coussement et al.,
2008; Oliver et al., 2000) due to the complex nature of References
patient falls in hospitals. A patient centered or unit centered American Nurses Association. (1999). Nursing-sensitive quality
approach to fall prevention has been suggested (Oliver, indicators for acute care settings and ANA’s safety and quality
2007). But if falls are classified as a “nursing problem” inte- initiative. Washington, DC: American Nurses Publishing.
grating a nursing approach to fall prevention seems key. Bandura, A. (1982). Self-efficacy mechanism in human
Additional research is needed to understand how nurses agency. American Psychologist, 37, 122–147.
provide care to fall risk patients. doi:10.1037/0003-066X.37.2.122
Blumer, H. (1998). Symbolic interactionism: Perspective and method.
Berkeley, CA: University Press.
Limitations Boltz, M., Resnick, B., Capezuti, E., & Shuluk, J. (2014). Activity
This study had several limitations: (a) Including obser- restriction vs. self-direction: Hospitalised older adults’ response
vations beyond interviews could have strengthened the to fear of falling. International Journal of Older People Nursing,
analysis by allowing the researcher to seek clarification if 9, 44–53. doi:10.1111/opn.12015
participants engaged in actions that were not consistent Bowers, B., & Schatzman, L. (2009). Dimensional analysis. In J. Morse,
P. Stern, J. Corbin, B. Bowers, K. Charmaz, & A. Clarke (Eds.),
with what they described. (b) As participants were recruited
Developing Grounded Theory: The second generation: Developing
from general inpatient adult medical and surgical units
qualitative inquiry Series (pp. 86–126). Walnut Creek, CA: Left
from two hospitals in Wisconsin the results might only be
Coast Press.
applied to these types of settings. Other hospital units, such
Brians, L. K.,Alexander, K., Grota, P., Chen, R., & Dumas,V. (1991).The
as rehabilitation, may produce different results because
development of the RISK tool for fall prevention. Rehabilitation
falls may be seen as an inevitable part of the rehabilitation
Nursing, 16, 67–69. doi:10.1002/j.2048-7940.1991.tb01181.x
program and its goal to regaining functional independence Brown, C., Friedkin, R., & Inouye, S. (2004). Prevalence and
for patients. outcomes of low mobility in hospitalized older adults.
Journal of the American Geriatrics Society, 52, 1263–1270.
doi:10.1111/j.1532-5415.2004.52354.x
Conclusions Brown, C., Redden, D., Flood, K., & Allman, R. (2009). The under-
Falls in older adult patients are a common occurrence in hos- recognized epidemic of low mobility during hospitalization of
pital settings. Because of high rates and associated injuries, older adults. Journal of the American Geriatrics Society, 57,
CMS has identified falls as a “never event” (CMS Medicare 1660–1665. doi:10.1111/j.1532-5415.2009.02393.x
Program, 2007). Hospitals have responded by setting zero Cameron, I., Gillespie, L., Robertson, M., Murray, G., Hill, K.,
falls goals and placing pressure on nursing staff to attain Cumming, R., & Kerse, N. (2012). Interventions for preventing
340 The Gerontologist, 2018, Vol. 58, No. 2

falls in older people in care facilities and hospitals. Cochrane measure set. Washington, DC: National Quality Forum.
Database of Systematic Reviews. Retrieved February 2, 2016, Retrieved March 4, 2016, from http://www.qualityforum.org/
from http://onlinelibrary.wiley.com/doi/10.1002/14651858. WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=22094
CD005465.pub3/full Oliver, D. (2004). Prevention of falls in hospital inpatients: Agendas
Centers for Medicare and Medicaid Services (CMS), HHS. (2007). for research and practice. Age and Ageing, 33, 328–330.
Medicare program: Changes to the hospital inpatient prospec- doi:10.1093/ageing/afh145
tive payment systems and fiscal year 2008 rates. Federal Registry, Oliver, D. (2007). Preventing falls and fall injuries in hospital:
72, 47129–48175. A major risk management challenge. Clinical Risk, 13, 173–178.
Charmaz, K. (2014). Constructing Grounded Theory (2nd ed.). doi:10.1258/135626207781572693
London: SAGE Publications Ltd. Oliver, D., Connelly, J., Victor, C., Shaw, F., Whitehead, A., Genc, Y.,
Coussement, J., De Paepe, L., Schwendimann, R., Denhaerynck, K., … Gosney, M. (2007). Strategies to prevent falls and fractures
Dejaeger, E., & Milisen, K. (2008). Interventions for preventing in hospitals and care homes and effect of cognitive impairment:
falls in acute- and chronic-care hospitals: A systematic review Systematic review and meta-analysis. British Medical Journal,

Downloaded from https://academic.oup.com/gerontologist/article/58/2/331/2736326 by guest on 18 March 2024

and meta-analysis. Journal of the American Geriatrics Society, 334, 82–85. doi:10.1136/bmj.39049.706493.55
56, 29–36. doi:10.1111/j.1532-5415.2007.01508.x Oliver, D., Hopper, A., & Seed, P. (2000). Do hospital fall pre-
Creditor, M. C. (1993). Hazards of hospitalization of the vention programs work? A systematic review. Journal
elderly. Annals of Internal Medicine, 118, 219–223. of the American Geriatrics Society, 48, 1679–1689.
doi:10.7326/0003-4819-118-3-199302010-00011 doi:10.1111/j.1532-5415.2000.tb03883.x
Halfon, P., Eggli, Y., Van Melle, G., & Vagnair, A. (2001). Risk of Oliver, D., McMurdo, M., Daly, F., & Martin, F. (2004). Risk factors
falls for hospitalized patients: A predictive model based on and risk assessment tools for falls in hospital in-patients: A sys-
routinely available data. Journal of Clinical Epidemiology, 54, tematic review. Age Ageing, 33, 122–130. doi:10.1093/ageing/
1258–1266. doi:10.1016/S0895-4356(01)00406-1 afh017
He, J., Dunton, N., & Staggs, V. (2012). Unit-level time trends in Rosenthal, M. B. (2007). Nonpayment for performance? Medicare’s
inpatient fall rates of US hospitals. Medical Care, 50, 801–807. new reimbursement rule. New England Journal of Medicine,
doi:10.1097/MLR.0b013e31825a8b88 357, 1573–1575. doi:10.1056/NEJMp078184
Inouye, S., Brown, C., & Tinetti, M. (2009). Medicare nonpay- Schatzman, L. (1991). Dimensional analysis: Notes on an alternative
ment, hospital falls and unintended consequences. New approach to the grounding of theory in qualitative research. In
England Journal of Medicine, 360, 2390–2393. doi:10.1056/ D. R. Maines (Ed.), Social organization and social process (pp.
NEJMp0900963 303–314). New York: Aldine De Gruyter.
Kannus, P., Seivenan, H., Palvanen, M., Jarvinen, T., & Parkkarri, J. Shorr, R., Chandler, M., Mion, L., Waters, T., Liu, M., Daniels, M.,
(2005). The prevention of falls and related injuries. Lancet, 366, … Miller, S. (2012). Effects of an intervention to increase bed
1885–1893. doi:10.1016/S0140-6736(05)67604-0 alarm use to prevent falls in hospitalized patients: A cluster
Kortebein, P., Ferrando, A., Lombeida, J, & Wolfe, R. (2007). Effect randomized trial. Annals of Internal Medicine, 157, 692–699.
of 10 days of bed rest on skeletal muscle in healthy older adults. doi:10.7326/0003-4819-157-10-201211200-00005
Journal of the American Medical Association, 297, 1772–1773. Strauss, A. (2008). Qualitative analysis for social scientists (14th
doi:10.1001/jama.297.16.1772-b ed.). New York: Cambridge University Press.
Lord, S., Sherrington, C., Menz, H., & Close, J. (2007). Preventing Tideiksaar, R., Feiner, C., Maby, J. (1993). Falls prevention: The effi-
falls in hospital (2nd ed.). Cambridge: Cambridge University cacy of a bed alarm system in an acute-care setting. The Mount
Press. Sinai Journal of Medicine, 60, 522–527.
MacCulloch, P., Gardner, T., & Bonner, A. (2007). Comprehensive Wanless, D. (2006). Securing good care for older people: Taking a
fall prevention programs across settings: A review of the lit- long term view. London: King’s Fund. Retrieved March 6, 2016,
erature. Geriatric Nursing, 28, 306–311. doi:10.1061/j. from www.kingsfund.ac.uk
gerinurse.2007.03.001 Waters, T. M., Daniels, M. J., Bazzoli, G. J., Perencevich, E., Dunton,
Mahoney, J. E. (1998). Immobility and falls. Clinics in Geriatric N., Staggs, V., … Shorr, R. (2015). Effect of Medicare’s nonpay-
Medicine, 14, 699–726. ment for hospital-acquired conditions: Lessons for future policy.
National Quality Forum. (2004). National voluntary consensus Journal of the American Medical Association, 175, 347–354.
standards for nursing-sensitive care: An initial performance doi:10.1001/jamainternmed.2014.5486