Barriers and challenges for preventing inpatients falls in tertiary healthcare facilities following the COVID-19 pandemic: a scoping review protocol

Abstract

Introduction

Hospital patients are at an increased risk of falls, which are a significant safety concern within healthcare settings.¹ Understanding how the COVID-19 pandemic has influenced fall risks is essential for identifying key factors that could inform future fall prevention strategies.² This scoping review aims to explore the barriers and challenges associated with preventing inpatient falls in the context of the post-COVID-19 environment.

Methods and analysis

The methodology for this scoping review follows the framework established by Arksey and O’Malley. A comprehensive literature search will be conducted using specific keywords to identify relevant published studies. Searches will be performed across selected electronic databases, including PubMed/MEDLINE, CINAHL, Scopus, ProQuest and Web of Science, covering publications from 2014 to 2024. This review will focus on a global perspective. Two authors will independently screen titles and abstracts to identify potential studies for inclusion. Studies meeting the inclusion criteria will be retrieved for full-text review, and their references will be assessed for relevance using the same criteria. The PRISMA flow diagram will guide the review process. Data will be extracted, analysed and charted according to categories from the selected publications.

Ethics and dissemination

This scoping review will provide a comprehensive overview of the barriers and challenges in preventing inpatient falls in the post-pandemic context. The findings will be disseminated through submission for publication in a scientific journal.

Registration details

This scoping review protocol is registered with Open Science Framework (OSF) available at https://osf.io/.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• This protocol aims to provide comprehensive insights into the barriers and challenges in preventing inpatient falls globally following the COVID-19 pandemic, a time when healthcare systems were significantly disrupted and patient care protocols were altered.

• The study addresses a critical gap by focusing on the post-pandemic period, where changes in healthcare infrastructure, staffing and patient management practices may have introduced new challenges in fall prevention, making this research particularly relevant for the current healthcare environment.

• The review will draw from a broad range of sources, including not only published papers from five major electronic databases but also grey literature, such as dissertations and conference proceedings, offering additional perspectives often overlooked in systematic reviews.

• While the scoping review seeks to identify key barriers and challenges, its findings may provide only a general indication of these issues rather than an exhaustive or precise reflection of global conditions.

• A key limitation is the restriction to English and Malay language publications, which may result in the exclusion of relevant studies published in other languages, potentially limiting the global applicability of the findings.

Introduction

The WHO declared COVID-19 a global pandemic on 11 March 2020, prompting widespread lockdowns to curb the transmission of SARS-CoV-2.¹ These restrictions reshaped healthcare delivery worldwide and disrupted routine patient management. Falls emerged as a potential presenting symptom of COVID-19,² and evidence suggests that patients with SARS-CoV-2 infection experienced markedly worse outcomes when hospitalised with fall-related injuries. For instance, COVID-19 patients who underwent surgery for femoral fractures had a fourfold increase in 30-day mortality compared with prepandemic levels.³ Such findings emphasise the heightened vulnerability of preventing falls in this population.

Beyond direct clinical risks, the pandemic also led to profound lifestyle disruptions. The closure of public spaces, including healthcare facilities and fitness centres, reduced physical activity for many individuals. This decline in movement negatively affected muscle strength, balance and coordination, all of which are crucial for fall prevention.⁴ Consequently, healthcare professionals faced additional challenges in managing fall risks among inpatients, particularly older adults, who were more susceptible to falls due to frailty, comorbidities and reduced mobility.

Falls in hospital settings, defined as unintentional events where patients end up on the floor or another lower surface, are among the most common adverse events in healthcare facilities that lead to severe consequences including physical injuries, emotional trauma, prolonged hospitalisation and even death.⁵ Hospitalised patients are especially vulnerable because of their unfamiliar surroundings, underlying illness and side effects of treatments, such as medication-induced dizziness or impaired cognition.⁶

Even before the COVID-19 crisis, preventing inpatient falls was a persistent challenge. Studies consistently documented multiple barriers, including high staff workloads, limited time to dedicate to fall prevention, inadequate staffing levels and poor interprofessional communication.⁷ Systemic limitations, such as insufficient funding and lack of standardised protocols, further complicated the implementation of effective prevention programmes.⁸

In the emergency department, healthcare providers (HCPs) identified additional barriers such as patient non-compliance with fall prevention recommendations, shortage of healthcare staff and limited incentives for fall prevention referrals.⁸

Patient-specific factors also present substantial challenges to fall prevention. For instance, patients with cognitive impairments, such as dementia, may struggle to follow safety protocols, increasing their risk of falls. Mobility issues, common among older adults and patients recovering from surgery, also elevate fall risk, as these individuals may have difficulty navigating hospital environments. In addition, non-compliance with fall prevention recommendations, such as refusal to use mobility aids or bed alarms, added further complexity to fall prevention efforts.⁷

The COVID-19 pandemic amplified existing challenges in inpatient fall prevention. As healthcare systems focused on managing COVID-19 cases, routine services including fall prevention were deprioritised. Staff redeployments to critical care units reduced the ability to monitor high-risk patients, while strict infection control policies limited family involvement in care. Prolonged inactivity during lockdowns led to widespread physical deconditioning among older adults and those with chronic illnesses. This left many patients more vulnerable to falls on admission.⁹

Although hospital falls and related injuries remain a persistent challenge in inpatient care, the COVID-19 pandemic introduced unique disruptions that have had lasting implications for fall prevention. For example, a study from a tertiary hospital in Taiwan reported that inpatient fall rates rose sharply during the early pandemic months, increasing from 0.41 to 1.24 per 1000 patient-days between January and May (2019 vs 2020), more than tripling during the height of COVID-19 restrictions.¹⁰ This escalation coincided with stringent visitor limitations and heightened demands on hospital staff, underscoring how reduced caregiver support and workforce strain can directly affect fall risk. These systemic vulnerabilities highlighted during the pandemic continue to shape fall prevention strategies in the post-COVID era, warranting focused examination of how health systems can adapt to persistent and emergent barriers. By integrating both established and emerging challenges, this review seeks to provide a comprehensive understanding of how the post-COVID landscape has reshaped the complexity of inpatient fall prevention.

A scoping review by Heng et al¹¹ focused specifically on patient education as a hospital-based fall prevention strategy.¹¹ Building on this, the present scoping review aims to consolidate global evidence on the barriers and challenges to fall prevention within the post-pandemic context. While prepandemic literature has extensively examined patient, staff and system-level barriers, the COVID-19 pandemic introduced additional pressures that continue to shape clinical practice.

By examining not only published research but also grey literature, such as dissertations and conference proceedings, this review will provide a broader and more comprehensive understanding of the current situation. The inclusion of grey literature is particularly valuable, as it may capture insights and data that have not been fully represented in peer-reviewed publications, offering a more holistic view of the challenges faced by healthcare systems worldwide.

Moreover, this review will highlight gaps in the literature, identify areas where fall prevention strategies have been disrupted or weakened due to the pandemic and propose areas for future research. It will also inform policymakers and HCPs about the need for updated fall prevention protocols that account for the postpandemic realities, such as staffing shortages, physical deconditioning in patients and the lasting impacts of healthcare system disruptions.

This scoping review seeks to systematically map the existing landscape of fall prevention initiatives and to delineate the principal barriers that healthcare systems must address to safeguard patient safety in the post-pandemic era, with particular emphasis on the challenges associated with preventing inpatient falls in the post-COVID-19 context.

Materials and methods

The methodology for this scoping review will follow Arksey and O’Malley’s seminal framework for mapping the essential concepts rapidly that drive a research area, as well as the primary sources and types of evidence that are accessible.¹² The framework provided by Arksey and O’Malley is often regarded as the pioneering framework for clarifying the usage and adoption of a scoping review methodology by postulating a starting point towards an evolutional methodological framework.^{13 14} Additionally, the augmented advancement to the previous methodology redefined by Levac et al¹⁵ and Colquhoun et al¹⁶ will also be employed in this scoping review to further consolidate the interpretation of the findings. Consequently, this scoping review will encompass five major steps as follows: (i) identifying the research question, (ii) identifying relevant studies, (iii) selecting eligible studies, (iv) charting the data and (v) collating, summarising and reporting the findings. We will hold a series of consultations with experts and key stakeholders for obtaining a comprehensive coverage of the findings beyond the up-to-date literature, by incorporating important perspectives of experts and key stakeholders whenever necessary. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses–Extension for Scoping Reviews (PRISMA-ScR) checklist and recommendation will be adhered to by this scoping review in order to conform to a standardised approach for conducting specific types of knowledge synthesis and also to identify the knowledge gaps by applying the evidence maps which includes both a systematic search of the body of literature and a visual presentation of outcome.¹⁷

Identifying the research questions

Research questions for scoping reviews typically aim to outline the breadth of available evidence, necessitating that these questions be broad and well-defined to ensure comprehensive coverage. For our scoping review, the primary research question that guides our investigation is as follows:

1. What are the barriers and challenges to preventing falls among inpatients in the post-COVID-19 pandemic period?

This research question is designed to identify and evaluate the various types of research published on the obstacles and difficulties associated with fall prevention among inpatients in hospital settings after the COVID-19 pandemic. Understanding these barriers is crucial for uncovering the specific challenges faced by healthcare workers in preventing falls under the new conditions introduced by the pandemic.

The focus of this research question aligns directly with the objectives of our scoping review, which are to explore and document the global barriers and challenges to preventing inpatient falls in the postpandemic context. This alignment ensures that our review will address the most relevant issues and provide valuable insights into improving fall prevention strategies in the evolving healthcare landscape.

Identifying relevant studies

A comprehensive search will be conducted across several key electronic databases, including PubMed/MEDLINE, Scopus, Cumulative Index to Nursing and Allied Health Literature (CINAHL), ProQuest and Web of Science. PubMed/MEDLINE, Scopus and Web of Science are essential for their extensive and effective coverage of medical and scientific literature. CINAHL will be included due to its specialisation in nursing and allied health research, which is directly relevant to the focus of this review. ProQuest, with its broad collection of full-text articles from diverse academic journals, will also be utilised to access relevant theses and dissertations.

To ensure a thorough and current review while minimising publication bias, grey literature will be incorporated. This includes dissertations and conference proceedings that may not be published in traditional journals but provide crucial insights into the barriers and challenges of fall prevention in inpatient settings. Grey literature can offer preliminary findings and data from studies conducted at academic institutions that may not yet be included in peer-reviewed publications, thereby enhancing the comprehensiveness of the review; and this review will be conducted using keywords such as ‘falls,’ ‘hospital,’ ‘barriers,’ ‘challenges’ and ‘prevention’518,20 (refer online supplemental file).

This review will focus on literature published within the last decade (2014 to 2024). This time frame is chosen to capture both pre- and post-COVID-19 pandemic, allowing for a comparative analysis of fall prevention barriers and challenges before and after the COVID-19 pandemic. By examining studies from this period, the review aims to highlight shifts in fall prevention practices and identify new challenges that have emerged as a result of the pandemic. This approach will provide a comprehensive understanding of the evolving landscape of fall prevention in inpatient settings and help in developing strategies to address both enduring and novel issues.

Selecting eligible studies

The flow of information through the different phases starting from identification of records through databases, screening for duplicates, eligibility assessment and then finally the inclusion of relevant literature will be illustrated in a flow chart (figure 1), according to PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses).²¹ The original flow diagram proposed by the Quality of Reporting of Meta-analyses has been modified to PRISMA to depict the numbers of identified records, excluded publications and finally included studies.²² This high-quality flow diagram can assist readers or reviewers to determine the logical steps of the whole process apart from describing the limit of the process.²³

Figure 1. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram.

In any systematic review, the inclusion and exclusion criteria significantly impact the scope and validity of the results. Therefore, it is crucial to apply these criteria broadly at the outset to ensure that relevant studies are incorporated and no pertinent research is excluded without a thorough evaluation.

The inclusion criteria for this scoping review are as follows:

1. Studies addressing barriers and challenges in preventing inpatient falls within tertiary healthcare facilities

2. Publications from 2014 to 2024;

3. Literature published in English or Malay.

The exclusion criteria are as follows:

1. Studies published outside the period of 2014 to 2024;

2. Research not focused on barriers and challenges in fall prevention within tertiary healthcare settings.

The initial stage of screening will involve a detailed review of titles and abstracts to prevent the allocation of time and resources to irrelevant publications. Two independent reviewers will evaluate all records to ensure the quality and consistency of the process. If there is any uncertainty regarding study inclusion, the full text of the article will be reviewed to assess whether it meets the inclusion criteria.

After removing duplicate entries from the databases, the titles and abstracts will be assessed by the two reviewers working independently to determine eligibility. In cases of disagreement, the reviewers will re-evaluate their justifications for inclusion or exclusion and, if necessary, assess the paper’s relevance based on its introduction and methodology. A consensus on eligibility will be reached through discussion and mutual agreement between the reviewers.

Each included article will undergo a comprehensive full-text review, and the references cited in these studies will also be examined for relevance and eligibility using the same criteria. For any relevant publications not accessible through the databases, efforts will be made to obtain full-text copies by contacting authors or journal publishers directly.

Charting the data

A data charting table will be utilised to systematically organise and present the results from all studies included in this scoping review. The table will capture essential details from each study, including the type of publication, the aim of the research, article categories and the identified barriers and challenges in preventing falls. This data will be systematically arranged in a spreadsheet for clarity and ease of analysis table 1.

Table 1. Indication for each item in the data extraction.

Item	Description
Type of publication	Includes all relevant settings such as peer-reviewed journals, research articles, narrative review and grey literature.
Aim	Focuses on published literature related to barriers in the prevention of falls among inpatients.
Category Articles	Covers various types such as original articles, opinions, case reports, short communications, conference proceedings and dissertations.
Population	Specifies the patient population studied in relation to fall prevention.
Barriers in prevention of falls	Identifies the obstacles encountered by healthcare workers in preventing inpatient falls within hospital settings.
Challenges in prevention of falls	Details the difficulties faced by healthcare workers in preventing falls among inpatients.

Collating, summarising and reporting the results

This scoping review aims to provide a comprehensive overview of the research rather than assessing the quality of individual studies. A scoping review is designed to synthesise and analyse a wide range of research and non-research sources to enhance conceptual clarity on a specific topic or field of evidence. To draw meaningful conclusions, it is essential to first identify multiple articles on a single topic, which will be aggregated and analysed as a cohesive unit.

The results of this scoping review will be synthesised and reported to highlight the barriers and challenges in preventing falls among inpatients in the post-COVID-19 era and examine whether variations exist across healthcare systems. This review will offer valuable insights for researchers, healthcare professionals and other stakeholders, setting the stage for further research. It may also pave the way for a subsequent systematic review. Additionally, the review will address limitations and identify research gaps to provide a clearer understanding of the barriers and challenges in fall prevention in the post-pandemic context.

As of September 2025, the literature search has been completed with the 1017 total number of articles. Title/abstract screening is currently in progress and will be followed by data extraction and synthesis, with anticipated completion by February 2026.

Patient and public involvement

Patients and the public were not involved in this study.

Ethics and dissemination

The scoping review protocol has been developed to outline the overall strategy and methodology for the review before the actual process begins. This protocol includes a detailed plan, objectives and methodology, which will guide the review’s execution. The findings of this scoping review will detail the barriers and challenges in preventing inpatient falls in the post-COVID-19 era, offering valuable insights for future research. The results will also serve as a resource for researchers, healthcare professionals and other stakeholders to understand the difficulties encountered in managing inpatient falls globally after the pandemic.

Any necessary modifications to the protocol during the review process will be documented, and these amendments will be reflected in the final scoping review findings. For dissemination purposes, the complete report of this scoping review will be submitted for publication in a scientific journal.

The study has been registered with the National Medical Research Register (NMRR ID-25–00178-HSY) Malaysia. Ethical clearance is not required for this study, as the scoping review methodology does not involve human subjects but rather reviews and analyses existing literature. Consequently, a waiver of consent has been granted by the Medical Research and Ethics Committee Malaysia for this study (OSF: https://osf.io/).