Nurses’ experiences of children’s fall accidents in South Korea: a phenomenological study

Abstract

Purpose

This study aimed to explore nurses’ experiences with hospitalized children’s fall accidents. The findings are intended to provide foundational data for developing strategies to strengthen patient safety for children.

Methods

Participants were purposively sampled. The sample consisted of eight nurses working in the pediatric departments of hospitals located in Daegu and Seoul in South Korea. All participants had experienced at least one fall accident involving a hospitalized child within the past year. Data were collected through in-depth interviews conducted between February 1 and April 30, 2025. The collected data were analyzed using Colaizzi’s phenomenological analysis method.

Results

The data analysis revealed four themes and 12 subthemes, which were derived from 111 significant statements and reflect pediatric ward nurses’ experiences with inpatient fall incidents. The four themes were: “encountering fall risks beyond nurses’ control,” “ineffective fall education and formalized safety practices,” “limitations of assessment tools and the growth of reflective practice,” and “moving toward comprehensive fall prevention and management strategies.”

Conclusion

Nurses recognized that the risk of pediatric falls was often beyond their control, and that fall prevention education did not always translate into practice. Reflective analysis of fall incidents, age- and patient-specific fall nursing interventions, and the establishment of an integrated support system are needed for effective fall prevention and management. These findings are expected to provide basic data to guide nursing care that prevents fall accidents and improves children’s patient safety.

INTRODUCTION

Unintentional injuries remain the leading cause of childhood death worldwide, and most are considered preventable. Children face a greater risk of severe outcomes from accidents due to immature physical functions and underdeveloped coping abilities [1,2]. Falls, defined as an unintended change in posture resulting in the body descending to a lower level or the ground [3], are the most common injury leading to hospitalization in children [4]. Although the incidence rate of pediatric falls varies, they constitute a worldwide problem, and children are particularly vulnerable [5]. Furthermore, these incidents range from minor contusions and abrasions to severe outcomes such as fractures, concussions, and intracranial hemorrhage [6,7]. In some cases, falls may result in fatal injuries or long-term treatment needs [3,8]. Importantly, falls also occur during hospitalization, requiring particular vigilance from healthcare providers. In one Korean university hospital, the fall incidence among children ≤13 years hospitalized from 2017 to 2018 was 0.7% [9]. In a general hospital from 2018 to 2023, the incidence among patients ≤18 years was 0.45% [7]. Recent US research reported a fall incidence rate of 0.05% to 0.1% among pediatric inpatients [10].

Pediatric falls differ meaningfully from adult falls. They are linked to developmental factors such as curiosity about surroundings, increased risk-taking, and insufficient caregiver supervision [3]. Hospitalized children, particularly those in the preschool age group (1–6 years), experience more falls than those in the school-age group (≥6 years) [6], underscoring the need for developmentally tailored prevention strategies. In hospitals, the inpatient room is the most frequent site of pediatric falls [7,11], with bed-related falls being the most prevalent [6,7]. Over half occur after the second day of hospitalization, suggesting that risks persist even after acclimatization to the hospital environment [7]. Since falls can happen at any time of day [7], continuous and comprehensive management is essential throughout hospitalization.

Nurses play a critical role in ensuring the safety of hospitalized children, given their prolonged and close contact [12]. Their responsibilities include educating children and caregivers about fall risks, maintaining a safe hospital environment, and providing post-fall treatment and care [12]. Furthermore, accurately assessing a child’s risk of falling is an essential component of pediatric nursing practice [13]. Given the unique characteristics of the pediatric population, specialized assessment tools have been developed to address differences from adult populations and have subsequently been validated for reliability [10]. Among these tools, the Humpty Dumpty Falls Scale (HDFS) is particularly valued because of its strong sensitivity across various age groups, genders, and environmental contexts [14]. Ongoing efforts to prevent pediatric falls continue to rely on the systematic use of these assessment instruments.

Quantitative studies have identified the frequency of pediatric falls and their associated risk factors [6,7,9]. However, these studies do not fully capture how nurses perceive and respond to such incidents in practice. Although qualitative studies have examined the experiences of nurses [15-17] and nursing students [18], they have largely focused on adult populations. Consequently, existing research has not sufficiently reflected the unique and complex characteristics of pediatric falls.

To design effective prevention strategies and strengthen nursing care, a qualitative analysis of nurses’ experiences with pediatric fall incidents is vital, as it uncovers the deeper meaning and essence of these events as understood by those who provide the closest care [19]. This study employed the phenomenological qualitative research method by Colaizzi [20]. In phenomenological qualitative research, interviews aim to elucidate the life-world, defined as the world of directly embodied experience, prior to preconceived notions or formal scientific knowledge. This process allows researchers to vividly apprehend lived experiences as they are genuinely perceived by participants [21]. The phenomenological method by Colaizzi [20] focuses on extracting the shared attributes across participants rather than emphasizing individual differences. The method facilitated analysis of nurses’ narratives without distortion. Phenomenology requires researchers to set aside preconceptions and assign meaning to participants’ experiences. By examining lived experiences, it can generate new insights into phenomena previously overlooked [21]. This approach also provides a structured and sequential analytic process, enhancing the credibility and dependability of findings [22]. Through this lens, the study sought to capture how nurses perceive and experience pediatric falls, the emotional and cognitive responses involved, and the implications for nursing practice.

By exploring the essence and meaning of nurses’ experiences with pediatric falls, this study aims to generate foundational data for developing evidence-based nursing practices in fall prevention and management. Ultimately, the research seeks to contribute to the advancement of safety for hospitalized children; to achieve this, the central research question is, “How do nurses perceive and experience pediatric falls?”

METHODS

Ethical statements: This study was approved by the Institutional Review Board of Daegu Catholic University (IRB No. CUIRB-2024-0009). Informed consent was obtained from all participants.

1. Study Design

This study employed the phenomenological analysis method by Colaizzi [20] to describe nurses’ experiences of children’s fall accidents. The study was reported in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines [23].

2. Study Participants

The participants were eight clinical nurses who were able to describe their experiences with hospitalized children’s fall accidents. To recruit them, the researchers explained the study’s purpose and methods to the heads of nursing departments at hospitals in Daegu and Seoul. After obtaining permission, recruitment notices were posted to facilitate voluntary participation. Sampling was initially purposeful and subsequently modified to achieve theoretical saturation. Nurses were enrolled in the study after providing written informed consent and agreeing to participate voluntarily.

The inclusion criteria were: nurses who had worked in pediatric departments, who had direct experience with hospitalized children’s fall accidents within the past year, and who were able to describe their experiences. Nurses who did not work in pediatric departments or who had not experienced pediatric falls in the past year were excluded.

Participants were purposively sampled. Participants were employed in the pediatric wards of eight medical institutions, including children’s specialty hospitals, general hospitals, and advanced general hospitals. They represented a spectrum from novice to mid-career nurses across diverse career stages. All participants were actively engaged in pediatric nursing, ensuring relevant and direct professional experience for the study’s objectives. This diversity of institutional representation allowed for a comprehensive exploration of pediatric nursing experiences across multiple healthcare settings and organizational contexts. The participants were well-suited to provide multifaceted and in-depth perspectives on pediatric nursing practice, thereby enhancing the richness, validity, and credibility of the qualitative findings.

3. Data Collection

Data collection was conducted through one-on-one interviews between February 1 and April 30, 2025. The interviews were conducted by a single researcher, who was a doctoral candidate with experience in qualitative research and pediatric nursing education. Interviews were held in private and quiet locations (e.g., offices, study cafés) to ensure participant privacy and confidentiality while minimizing distractions. Each participant was interviewed once or twice, with a total duration between 1 and 2 hours. To ensure participants’ comfort, interviews began with general questions before progressing to more in-depth topics. Due to certain circumstances, including health-related issues, some interviews were conducted remotely via video or phone calls.

The interview questions were initially developed based on prior studies concerning pediatric falls and fall prevention nursing [7,24]. Following the literature review, an initial set of questions was drafted in consultation with pediatric nurses who possessed more than 10 years of clinical experience. This process ensured that the draft adequately captured critical issues encountered in actual clinical practice. The interview questions were finalized through a thorough review and confirmation process conducted by the two researchers. The core research question guiding this study was: “What is the essence of pediatric ward nurses’ experience with fall prevention nursing?” To address this question, primary interview questions were developed and used to explore the phenomenon (Table 1). These questions were specifically designed to elicit detailed narratives from participants regarding their experiences with fall incidents involving hospitalized children.

Table 1.

Research questions

	Question
Core research question	• What is the essence of pediatric ward nurses’ experience with fall prevention nursing?
Primary interview questions	• What transpired within you when you experienced a child’s fall incident, and what significance did that experience hold for you?
	• What transformations did you undergo as a nurse and as an individual through fall-related experiences, and what meaning did those changes carry for you?
	• What experiences did you encounter while utilizing pediatric fall risk assessment tools, and what insights did you have throughout that process?
	• What experience do you regard as most significant while practicing fall prevention nursing, and what meaning does that experience embody for you?
	• What experiences did you have while communicating with and educating caregivers regarding patient safety, and what emotions did you experience within those relationships?
	• What limitations or needs do you experience as a nurse within the pediatric fall prevention environment, and what significance does that hold for you?

The researcher used active listening and asked follow-up questions to elicit deeper accounts. Throughout the interviews, the researcher maintained a phenomenological attitude, bracketing personal judgments and interpretations to focus solely on participants’ lived experiences. Participants were encouraged to provide concrete, detailed narratives. Open-ended questioning techniques facilitated free expression of their experiences.

All interviews were audio-recorded and transcribed verbatim by the researcher, including observational notes. Since no new information emerged during the interview with the eighth participant and the same concepts and categories were repeated in the data, it was determined that theoretical saturation had been reached, and the interviews were terminated thereafter.

4. Ethical Considerations

All participants were fully informed of the study’s purpose and procedures. They were assured that participation was voluntary and that they could decline to answer any questions or withdraw from the interview at any time. Furthermore, they were guaranteed that anonymity and confidentiality would be strictly maintained. Participants were also informed that the one-on-one interviews would be recorded and that all data would be destroyed upon completion of the study. Written informed consent was obtained from each participant, who received a small token of appreciation for their time.

For confidentiality, all data were anonymized with participant codes, and transcripts were stored on a password-protected computer accessible only to the researcher. The data will be retained for 3 years following the publication of the research results; subsequently, electronic files will be permanently deleted, and all printed materials will be shredded for permanent disposal.

5. Data Analysis

Data analysis followed the seven-step phenomenological method by Colaizzi [20]. First, the researcher repeatedly read the interview transcripts to gain a comprehensive understanding of the participants’ experiences. This immersion in the data allowed the researcher to set aside preconceived notions and ensure that the participants’ voices were accurately represented. Next, significant statements directly related to fall accidents were extracted from the transcripts, providing foundational insights into how participants perceived and experienced such incidents.

The researcher then interpreted the underlying meanings of these statements, deriving them as “formulated meanings.” These meanings were grouped into subthemes, which were subsequently integrated into broader themes and overarching concepts. This process enabled the analysis of structural meanings emerging from nurses’ experiences with pediatric falls within both nursing and practical contexts.

Finally, themes were synthesized into an exhaustive description of participants’ experiences, from which the fundamental structure of the phenomenon was derived. To validate the findings, the analyzed results were returned to participants for verification (member checking) to confirm that the interpretations accurately reflected their lived experiences.

6. Rigor

To ensure the trustworthiness of the study, rigor was evaluated using the four criteria by Guba and Lincoln [25]: credibility, transferability, dependability, and confirmability. Credibility was enhanced through the use of open-ended questions and member checking, including cross-verification of interview transcripts with participants. Transferability was strengthened by employing purposeful sampling until data saturation was achieved. The findings were further validated by two participants through additional member checking. Dependability was established by strict adherence to the phenomenological method by Colaizzi [20] and through regular discussions of the research process and findings among the research team. Confirmability was maintained through the researchers’ commitment to objectivity and consistent efforts to minimize personal bias during both data collection and analysis.

RESULTS

1. Characteristics of the Participants

The final sample included eight female nurses, aged 26 to 52 years (mean±standard deviation [M±SD]=39.6±10.1). Their total clinical experience ranged from 3.5 to 30 years (M±SD=15.4±10.4), and their pediatric department experience ranged from 1.2 to 20 years (M±SD=10.3±7.6) (Table 2).

Table 2.

Characteristics of nurses participating in the study (N=8)

Participant	Gender	Age (yr)	Total clinical experience (yr)	Pediatric department experience (yr)	Type of hospital	Type of pediatric department
1	Female	42	16	4	Advanced general hospital	General pediatric ward
2	Female	45	19	17	Advanced general hospital	General pediatric ward
3	Female	31	5.5	5	Advanced general hospital	General pediatric ward
4	Female	52	30	20	Children’s specialty hospital	General pediatric ward
5	Female	28	3.5	1.2	General hospital	General pediatric ward
6	Female	26	3.5	3.5	Advanced general hospital	General pediatric ward
7	Female	51	27	18	Pediatric hospital clinic	General pediatric ward
8	Female	42	19	14	Children’s specialty hospital	General pediatric ward

2. Data Analysis Results

An analysis of the data was conducted to address the research question, “How do nurses perceive and experience pediatric falls?”, resulting in the extraction of 111 significant statements. From these statements, 12 open codes (subthemes) were generated and subsequently grouped into four major themes, culminating in the identification of four overarching themes (Table 3).

Table 3.

Themes and subthemes of participants’ lived experiences with children’s falls

Themes	Subthemes	Qualitative data
Encountering fall risks beyond nurses’ control	Limitations of caregiving by a single person	Since there’s only one caregiver, they have to step away sometimes—like to prepare formula or whatever. (Participant 3)
	Structural hazards in the physical environment	The height of the bed rails appears to be an important factor as well. (Participant 1)
Ineffective fall education and formalized safety practices	Inefficiency of undifferentiated education that ignores developmental stage differences	Even though fall cases differ by age, our nurses give the same instructions to everyone. (Participant 2)
	Limitations of text-oriented and theoretical educational delivery	For fall prevention nursing, we provide caregiver education using written materials... but it feels like they just accept it passively. (Participant 5)
	Fall education as a way to avoid responsibility	We hand the guide out, attach it to the bed rails and anywhere else it can be clipped, and tell them, ‘Please read it.’ (Participant 3)
Limitations of assessment tools and the growth of reflective practice	Perfunctory fall risk assessment	I question whether fall risk assessment scales can accurately evaluate a child’s fall risk. (Participant 5)
	Reflective thinking and preventive practice prompted by patient safety reports	Since you think about what caused it and write down improvement plans, it helps prevent recurrence in the future. (Participant 2)
	Fall nursing guided by experience and intuition	When a fall happens, seniors immediately check vitals and assess, but when I was new, I didn’t know what to do—I skipped vitals and just called the doctor right away. (Participant 3)
Moving toward comprehensive fall prevention and management strategies	Structural improvement of environmental risk factors	If laws could be changed to require removing thresholds in children’s hospitals, or making corners more rounded... (Participant 7)
	Differentiated fall nursing according to age and patient characteristics	We created posters showing fall cases by age, and for each case, we’d tell mothers. (Participant 2)
	Fostering collaborative safety culture through caregiver engagement	It would be great if more fall-related materials and diverse fall prevention programs were developed so people could truly understand that falls can be a serious problem. (Participant 5)
	Establishing an integrated support system to protect healthcare providers	If there were systems to protect medical staff, nurses might feel somewhat better. (Participant 4)

Nurses encountered fall risks that were beyond their control and perceived fall education as ineffective and perfunctory because it did not adequately account for children’s developmental stages. Although they recognized the limitations of existing fall assessment tools, they also identified patient safety reports as effective mechanisms for preventing recurrence through reflective processes. Nurses further acknowledged the importance of structural improvements to address environmental risk factors, as well as the establishment of support systems. Consequently, they provided differentiated fall care based on children’s ages and characteristics, while striving to foster a culture of safety.

1) Theme 1: encountering fall risks beyond nurses’ control

(1) Subtheme 1: limitations of caregiving by a single person

Nurses described fall incidents that occurred when caregivers were left to care for children alone. Because only one caregiver is permitted to stay with hospitalized children, children are often left unattended when caregivers briefly leave the bedside to use the restroom or prepare feeding and diaper supplies. To prevent such incidents, nurses instructed caregivers to request nursing assistance whenever they needed to step away, even for a short time. However, caregivers sometimes assumed that a brief absence would not cause problems. Nurses emphasized the difficulty of proactively preventing falls in situations where caregivers temporarily left, leaving the child without supervision.

• “Most of the time it happens when parents look away for just a moment. But they can’t watch constantly, right? Since there’s only one caregiver, they have to step away sometimes—like to prepare formula or whatever. We usually tell them, ‘Please call the nurse if you need to go anywhere, even just to the bathroom,’ but you know, it’s hard to keep calling us all the time. So, they think, ‘I’ll just be gone for a second, it should be fine,’ and then, oops, the fall happens. We’ve seen quite a few accidents like that.” (Participant 3)

• “Also, some caregivers don’t provide adequate supervision when their child is hospitalized. When that happens, during our ward rounds, we often find children left alone in their beds. Then we either place the child on the floor mat or repeatedly remind the caregiver. All we can do is keep reminding them during every round: Please watch them closely, they could fall.” (Participant 8)

(2) Subtheme 2: structural hazards in the physical environment

Nurses also identified environmental risk factors within the hospital setting as contributors to pediatric falls. Structural issues included ward design, bed height, and safety equipment. Outdated facilities, adult-oriented bed structures, and curtains obstructing visibility were seen as major environmental barriers complicating fall prevention efforts. Nurses expressed frustration that, while vigilance could reduce risks, structural factors in the hospital environment continued to create hazards beyond their control.

• “The height of the bed rails appears to be an important factor as well. There were many cases where infants fell out of bed while their mothers were sleeping. This seems to happen frequently because the facilities are inadequate.” (Participant 1)

• “Bed-related falls used to be common, but nowadays, instead of using beds, they use floor mats. So, children often leave the hospital room to places like the hallway and play on sofas, and that’s where falls occur more frequently.” (Participant 7)

2) Theme 2: ineffective fall education and formalized safety practices

(1) Subtheme 1: inefficiency of undifferentiated education that ignores developmental stage differences

Nurses observed that the circumstances and types of falls varied depending on children’s developmental stage, illness status, and caregiver characteristics. However, they reported that fall prevention education was provided uniformly, without accounting for these differences. Such undifferentiated education was perceived as less effective in preventing falls. In pediatric wards that admit patients ranging from newborns to adolescents, nurses realized that standardized guidelines and uniform education programs had clear limitations.

• "The types of falls vary by age. At 5–6 months, they can roll over, so they fall while rolling. At 6 months, they can sit, so they fall after their mother sits them down. At 12 months, they can stand while holding on, so they fall while standing by the bed rails. Even though fall cases differ by age, our nurses give the same instructions to everyone: ‘Raise the side rails and don’t leave the bed unattended.’” (Participant 2)

(2) Subtheme 2: limitations of text-oriented and theoretical educational delivery

Nurses described limitations in fall prevention education with respect to enhancing caregivers’ awareness and understanding. Since many pediatric inpatients are young children, education is primarily directed at their parents. However, nurses often found that caregivers had difficulty concentrating on fall prevention education because they were required to absorb a large volume of information simultaneously. Moreover, they noted that fall education, usually delivered through written materials and brief explanations, did not effectively help caregivers grasp the seriousness of fall risks or consistently apply preventive practices in daily routines.

• “There’s too much caregiver education. ‘When they have diarrhea, you should do this, and when they have a fever, you should do that’—they provide so much information, but caregivers aren’t ready to absorb it all. They have no breathing room when their child is suffering... We explain about falls too, but caregivers just seem to respond with ‘Well...’” (Participant 4)

• “Talking to the child is pointless, so it’s really more about caregiver education. The most frequent instruction seems to be to watch the child carefully and prevent falls. For fall prevention nursing, we provide caregiver education using written materials... but it feels like they just accept it passively. Honestly, it felt like information going in one ear and out the other.” (Participant 5)

(3) Subtheme 3: fall education as a way to avoid responsibility

Although fall prevention education should serve as an active measure to prevent accidents, nurses observed that in practice it often became a formal procedure designed to demonstrate that education had been provided, rather than to achieve genuine prevention. Nurses expressed concern that fall education was being reduced to a bureaucratic task intended to deflect responsibility, rather than functioning as a meaningful safety intervention. This shift created feelings of powerlessness and skepticism about their professional role.

• “For example, we put signs on wardrobes, in hallways, saying ‘Beware of Falls’ and ‘Beware of Slipping’—visible everywhere, and even on IV poles. Since they move the IV pole around frequently... No matter how much we tell them, if they just say they didn’t hear us or don’t know, that’s the end of it.” (Participant 4)

• “(Worried they might say they didn’t receive prevention training) We provide them with a guide on fall prevention activities. We hand it out, attach it to the bed rails and anywhere else it can be clipped, and tell them, ‘Please read it.’”(Participant 3)

3) Theme 3: limitations of assessment tools and the growth of reflective practice

(1) Subtheme 1: perfunctory fall risk assessment

Nurses reported that while fall risk assessment tools are widely used, they often fail to align with the realities of pediatric fall prevention in clinical practice. Although the tools, such as the HDFS, are systematically structured, nurses felt they did not always reflect actual conditions in the ward or the nuanced risks of individual patients. Inconsistencies in scoring between evaluators, as well as ambiguities in defining severity levels, created confusion. For example, nurses were uncertain whether minor illnesses, such as a cold, should be marked as risk factors. This led to skepticism about whether these scales genuinely supported fall prevention or were being used merely as formal requirements.

• “We use Humpty Dumpty within 24 hours, when conditions change, or with room transfers. The problem is, scores vary depending on who’s doing the assessment. If there’s a neurological or respiratory diagnosis, the score goes up, but there aren’t any specific criteria for respiratory issues, so even in our unit, opinions differ. The tool alone isn’t enough, so we automatically classify under 24 months, emergency room (ER) admissions, and neonatal intensive care unit (NICU) babies as high-risk. We use additional criteria beyond the standard tool.” (Participant 6)

• “Adult fall risk assessment scales have criteria for reassessment when a patient’s condition changes—like reassessing if they start taking psychotropic medications or their condition deteriorates... It’s difficult to determine when to reassess children. I question whether fall risk assessment scales can accurately evaluate a child’s fall risk.” (Participant 5)

(2) Subtheme 2: reflective thinking and preventive practice prompted by patient safety reports

Nurses noted that the process of writing patient safety incident reports encouraged them to reflect on fall risk factors, incident causes, and potential preventive measures. Writing according to the five Ws and one H principle (who, what, when, where, why, and how) prompted them to analyze the circumstances of each event, consider contributing factors, and propose improvements. Nurses felt this reflective process helped prevent recurrence by turning reporting into a learning opportunity.

• “The safety report form seems absolutely essential. Looking at the patient safety incident form, it requires detailing the circumstances of the incident using the 5W1H principle. It prompts you to check for fall risks, prevention activities, accompanying persons, and how the fall occurred. Having sections for incident causes and improvement plans seems beneficial... Since you think about what caused it and write down improvement plans, it helps prevent recurrence in the future.” (Participant 2)

(3) Subtheme 3: fall nursing guided by experience and intuition

Nurses emphasized that their accumulated experience and intuition were vital in guiding fall prevention practices. While novice nurses, lacking sufficient clinical exposure, tended to provide uniform education and care for all patients, experienced nurses were able to identify subtle differences in risk and tailor their interventions accordingly. Through years of direct encounters with diverse children and caregivers, senior nurses developed the ability to quickly recognize high-risk situations and act preemptively.

• “When taking history, you can tell some kids are going to fall—they’re too rambunctious. Senior nurses watch those kids closely, but new nurses can’t spot it yet. When a fall happens, seniors immediately check vitals and assess, but when I was new, I didn’t know what to do—I skipped vitals and just called the doctor right away. It was tough for junior nurses.” (Participant 3)

4) Theme 4: moving toward comprehensive fall prevention and management strategies

(1) Subtheme 1: structural improvement of environmental risk factors

Nurses emphasized that the structural characteristics and physical environment of hospital wards are key contributors to pediatric falls. They felt it was essential to comprehensively improve the hospital environment with child safety as a priority, including the design of patient rooms. In addition, they recognized the need for long-term, policy-level improvements to hospital infrastructure.

• “Children... seem to fall off beds most often, and also frequently fall from chairs. Unlike adult patients who trip while walking or fall due to twisted ankles, they often fall from that position. If possible, it would be good to have a structure where the bed is laid flat on the floor, with cushions placed underneath... like a kindergarten setting. Caregivers probably wouldn’t oppose such a structure.” (Participant 5)

• “If laws could be changed to require removing thresholds in children’s hospitals, or making corners more rounded... so kids won’t get hurt even if they bump into things while playing... since children can get injured, it would be better to design it this way.” (Participant 7)

(2) Subtheme 2: differentiated fall nursing according to age and patient characteristics

Nurses recognized the need for tailored fall prevention strategies based on children’s age and health status. They noted that fall prevention education should reflect the distinct causes and risk factors associated with each developmental stage. Nurses emphasized the importance of clinical intuition and differentiated management for specific circumstances, such as post-sedation states, neurological disorders, or situations where caregivers demonstrated low comprehension. To address the limitations of existing fall risk assessment tools, additional criteria were introduced in practice. For example, patients under 24 months, ER patients, and those with prior NICU experience were automatically designated as high-risk groups. This allowed the establishment of a customized assessment system tailored to each ward’s patient population.

• “By 20 months, they can run on both feet, so even if you raise the side rails, they’ll step on top and climb over. We created posters showing fall cases by age, and for each case, we’d tell mothers, ‘At 6 months, they can sit up, right? If they can sit, you shouldn’t leave them sitting up unattended.’ Taking this approach improved things.” (Participant 2)

• “The fall assessment tools alone weren’t sufficient, so our ward designates all patients under 24 months as high risk. We also use another tool to assess patients such as emergency department visitors, those under 24 months, or infants who were in the NICU, categorizing them as high risk regardless.” (Participant 2)

(3) Subtheme 3: fostering collaborative safety culture through caregiver engagement

Nurses highlighted that caregivers should not be viewed merely as recipients of education but as active partners in preventing childhood falls. Because caregivers’ awareness and levels of participation varied widely, nurses stressed the need for practice-oriented education tailored to caregiver characteristics, using tools such as visual materials and multimedia resources.

• “When admitting patients, we’re often too busy to thoroughly explain the fall prevention pamphlets. It would be better to invest time explaining them in detail personally, or perhaps create educational videos. More education seems necessary too.” (Participant 1)

• “In addition to paper-based education methods, I wish there were educational materials that could better capture caregivers’ interest and make them think, ‘If our children fall, they can get hurt much more severely than adults, so we need to be careful.’ It seems like many caregivers think, ‘Even if they fall... even if they trip...’ It would be great if more fall-related materials and diverse fall prevention programs were developed so people could truly understand that falls can be a serious problem.” (Participant 5)

(4) Subtheme 4: establishing an integrated support system to protect healthcare providers

Nurses acknowledged that preventing falls cannot be achieved through individual effort alone. They identified the importance of technical, policy, and staffing support to effectively reduce risks. Considering the unpredictability of children’s behavior, they emphasized the value of auxiliary measures such as real-time monitoring systems, risk detection technologies, and robotic assistance. Furthermore, nurses expressed concern about the current system, where they bear full responsibility for fall incidents. They noted that this structure contributes to emotional burden and job burnout, and they stressed the need for institutional safeguards to protect healthcare providers from this burden.

• “With more medical staff, they could watch the baby while preparing formula or provide more attentive care. It would be great to have support staff who can assist the mothers. Wouldn’t that reduce falls? Mothers have to carry the meal trays themselves. It would be nice to have a robot that delivers the trays.” (Participant 6)

• “During incident processing, large hospitals have insurance company staff or relevant personnel come to handle settlements. That way, staff don’t have to endure unnecessary stress, but otherwise it’s really emotionally draining. If there were systems to protect medical staff, nurses might feel somewhat better.” (Participant 4)

DISCUSSION

This study employed the phenomenological analysis method by Colaizzi [20] to explore nurses’ experiences of falls among hospitalized children.

The first theme, “encountering fall risks beyond nurses’ control,” reflects the reality that many accidents are influenced by factors outside a nurse’s direct authority, such as reliance on a single caregiver and the physical layout of the hospital environment. These findings align with previous qualitative studies on nurses’ experiences with adult patient falls [16], which also emphasized the challenges of controlling fall risks despite preventive efforts. Although the causes and populations differ, a consistent theme emerges: nurses frequently experience a sense of limited control over falls. Parental or caregiver inattention has previously been identified as a major contributor to pediatric falls [26]. Falls occurred not only when caregivers left the child’s side but also when they were physically present but distracted [7,27]. To address these risks, institutional and administrative improvements are necessary, including the deployment of auxiliary support staff who can watch children during caregivers’ brief absences or assist with daily ward activities. Ultimately, optimizing nurse-to-patient ratios is fundamental for alleviating the excessive cognitive and physical workload, which often leads to overlooked fall risks in busy pediatric wards.

Additionally, most hospital facilities and equipment remain designed according to adult standards, which are unsuitable for children’s smaller physiques. Because children’s motor and cognitive abilities are underdeveloped, they are less capable of responding to dangerous situations, thereby increasing the likelihood of serious injuries [1]. In clinical practice, nurses should make specific adjustments regarding bed use, the application of protective equipment, and the scope of in-room activities according to the child’s age, mobility, and disease characteristics. Hospitals must therefore invest in safer pediatric environments by lowering bed heights, minimizing rail gaps, providing child-specific furniture, and installing non-slip flooring [28]. Fostering an inherently safer physical environment facilitates the establishment of more robust safety standards that ensure consistent protection for children at all times.

The second theme, “ineffective fall education and formalized safety practices,” highlights the lack of tailored education for caregivers, the weak connection between theoretical information and practical application, and the tendency to conduct education as a formality to avoid responsibility rather than as meaningful prevention. Nurses identified fall prevention education as a critical strategy for reducing pediatric falls, consistent with prior studies emphasizing education for both children and caregivers [5,24,29]. The findings of this study are distinctive in pediatric settings, as the significance of developmental differences is less emphasized in adult fall-prevention research [15,16,30]. Thus, pediatric fall prevention requires an approach uniquely tailored to children’s developmental stages. For education to be effective, it should be repeated throughout hospitalization and delivered using diverse, engaging communication methods [24]. Nurses, as key patient safety advocates, must develop creative and practical strategies to ensure that fall prevention education is not only provided but also meaningfully applied [31]. Interactive and practical educational programs that actively involve caregivers are essential for promoting meaningful behavioral change.

The third theme, “limitations of assessment tools and the growth of reflective practice,” highlights the tension between formal tools and nurses’ reliance on clinical judgment. Accurate fall risk assessment is fundamental to prevention programs [24]. Pediatric-specific tools have been developed to address differences from adult populations [14] and their reliability has been validated [9]. Yet, participants in this study reported frequent mismatches between tool-based risk scores and real-world conditions, including the developmental stage of children, the ward environment, and their own professional judgment. For example, although the HDFS is valued for its sensitivity [9,14], it does not adequately account for the rapid month-to-month developmental changes in infants. Nurses therefore found these tools insufficient on their own, relying instead on their accumulated knowledge and intuition to guide preventive care. To address these limitations, specialized fall risk assessment tools for children must be further developed and rigorously validated. Effective pediatric fall prevention should therefore begin with accurate risk assessment using validated and reliable instruments.

The fourth theme, “moving toward comprehensive fall prevention and management strategies,” encompassed structural improvements to environmental risk factors, differentiated fall nursing according to patient age and characteristics, fostering a collaborative safety culture with caregiver engagement, and establishing an integrated support system to protect healthcare providers. Key strategies included selecting beds appropriate to children’s developmental characteristics, removing environmental obstacles, and systematically organizing ward structures [24]. These considerations are particularly critical for children under 5 years of age, who are at higher risk and require age-appropriate facilities and equipment [5]. Because younger children tend to have higher fall risk scores [9,27], they require more intensive monitoring and targeted interventions. Fall education that emphasizes age-related risks has been shown to improve caregivers’ knowledge and behaviors [29], underscoring the importance of individualized and developmentally tailored nursing care. When nurses and caregivers establish collaborative and supportive relationships, patient safety practices are strengthened [32]. Nurses therefore play a crucial role in engaging caregivers, providing them with relevant knowledge, and encouraging active participation in fall prevention efforts. Environmental and behavioral improvements can be achieved through engineering enhancements and strengthened policies [5]. For example, in current clinical practice, the use of electronic bed sensors and alarm systems enables rapid nurse responses to patient movement [17]. Extending such innovations to continuous monitoring and risk detection technologies may further strengthen fall prevention in pediatric wards.

Falls are widely recognized as a major patient safety threat and are used as quality indicators for healthcare institutions [33]. Because fall incidents can negatively affect hospital quality ratings, nurses often experience heightened stress, burden, and fear of blame [16]. Our findings reveal that such an environment may reduce fall prevention nursing to a procedural formality, fostering feelings of helplessness and skepticism. To address these challenges, the participants’ experiences suggest that the focus must shift from individual accountability to a supportive safety culture that encourages open dialogue and collective responsibility. When individual nurses are held solely responsible for fall incidents, broader environmental and policy shortcomings remain unaddressed, leaving the underlying problems unresolved and accidents likely to recur. Nurses who have experienced patient safety incidents often report inadequate peer support, accompanied by distress and disappointment with how such events are managed [19]. Similarly, nursing students encountering falls during clinical training viewed it as unreasonable that nurses were expected to bear sole responsibility [18].

Within organizational cultures that emphasize individual blame, the focus often shifts to concealing mistakes and deflecting responsibility out of fear of criticism and stigma. This dynamic impedes the identification of root causes and obstructs the development of effective solutions [34]. Our results suggest that rather than attributing blame to individuals, a systemic support structure is needed—one that prioritizes identifying causes, implementing improvements, and fostering a culture of active prevention. Consequently, institutional-level integrated support systems are essential for reducing the burden on individual nurses and promoting shared responsibility for patient safety. Specifically, such systems should include standardized reporting protocols that emphasize learning rather than punishment, as well as staffing levels that adequately reflect the high-intensity demands of pediatric developmental care.

In this context, it is noteworthy that our participants’ perspectives diverged from previous findings [19], in which nurses reported hesitation to file reports because of fear of criticism, stigma, or loss of professional confidence. In contrast, participants in this study viewed reporting as a valuable opportunity for reflection and proactive prevention. This contrast suggests a meaningful shift in perceptions of patient safety reporting. Because reflection allows for in-depth analysis of clinical events [35], it enables nurses to document cases, integrate experiential knowledge, and critically evaluate limitations in order to propose effective preventive solutions [36]. Ultimately, such reflective practice is essential following any safety incident and represents a fundamental step toward long-term prevention. From a policy perspective, these individual reflective efforts should be supported through strengthened pediatric fall prevention and management guidelines that are more explicitly linked to patient safety reporting systems.

This study is significant in that it examines pediatric fall experiences across diverse hospitals. However, the limited number of participants from each institution constrained the ability to conduct comparative analyses of setting-specific characteristics. Additionally, because this study was conducted in specific cities, and most participants were female nurses working in general wards, the findings may not fully represent the perspectives of male nurses or those employed in specialized units, such as the NICU or pediatric emergency department across different geographical regions. Future research should therefore include larger and more diverse cohorts, encompassing a wider range of clinical settings and demographic backgrounds, to achieve a more comprehensive understanding of pediatric fall prevention.

Despite these limitations, this study demonstrates that effective pediatric fall prevention must extend beyond simple education or reliance on tool-based assessments. It requires practical interventions tailored to children’s developmental stages and caregiving contexts. Importantly, fall prevention should not depend solely on nursing vigilance; structural environmental modifications, such as optimizing bed rail safety and visibility, are essential to reducing the burden of constant monitoring. Moreover, fall risk assessment tools must be reconstructed to better reflect the actual causes of falls, including caregiver behavior and children’s momentary activity patterns. In addition, caregiver education should move away from generic, one-time explanations toward repeated, situation-specific guidance that offers practical behavioral strategies applicable to real ward scenarios. Finally, pediatric fall prevention must transition from an individual responsibility to an institutional priority. For safety reporting to function as more than a purely administrative task, it should be integrated with clinical nursing guidelines to promote a team-based safety culture. This multifaceted approach, encompassing clinical, educational, environmental, and policy dimensions, can alleviate nurses’ psychological burden and establish shared responsibility for patient safety. Ultimately, these integrated efforts are essential for improving fall management effectiveness and ensuring the safety of hospitalized children.

CONCLUSION

This study explored nurses’ experiences with fall incidents involving hospitalized children. Their accounts were organized into four themes: “encountering fall risks beyond nurses’ control,” “ineffective fall education and formalized safety practices,” “limitations of assessment tools and the growth of reflective practice,” and “moving toward comprehensive fall prevention and management strategies.” Nurses emphasized that undifferentiated fall prevention education and perfunctory fall risk assessments were often ineffective. Instead, they engaged in reflective analyses of fall incidents to identify better solutions. This study offers unique insights into pediatric patient safety by underscoring the importance of tailoring fall prevention strategies to children’s developmental trajectories. In particular, there is a clear need to develop more sophisticated assessment instruments that reflect rapid, month-to-month developmental changes in infants’ activity levels. Furthermore, structural improvements to environmental factors, caregiver engagement, and the establishment of integrated support systems to protect healthcare providers are vital for effective fall prevention and management.