Fall Prevention Decision Making of Acute Care Registered Nurses

Abstract

OBJECTIVE:

The aim of this study was to examine acute care registered nurses’ (RNs’) fall prevention decision-making.

BACKGROUND:

The RN decision-making process related to fall prevention needs to be investigated to ensure that hospital policies align with nursing workflow and support nursing judgment.

METHODS:

Qualitative semistructured interviews based on the Critical Decision Method were conducted with RNs about their planning and decision making during their last 12-hour shift worked.

RESULTS:

Data saturation was achieved with 12 RNs. Nine themes emerged related to the RN decision-making process and included hospital-level (eg, fear of discipline), unit-level (eg, value of bed alarm technology), and nurse-level (eg, professional judgment) factors that could influence fall prevention.

CONCLUSIONS:

Nursing administrators should consider a multilevel approach to fall prevention policies that includes promoting a practice environment that embraces self-reporting adverse events without fear of shame or being reprimanded, evaluating unit-level practice and technology acceptance and usability, and supporting autonomous nursing practice.

Fall death rates have been increasing since 2007, and injuries from falls are 1 of the most reported sentinel events among US healthcare facilities.^1,2 Numerous investigators have demonstrated the relationship between nursing care and hospital-acquired falls.^3–7 However, to date, little attention has been paid to acute care registered nurses’ (RNs’) decision making as they work to prevent hospital-acquired falls. Revealing this process can provide new insights about RNs’ decisions that are vital to preventing falls. This information could better inform how nursing administrators implement fall prevention programs in the acute care setting.

Researchers have used focus groups, observation and time-motion studies, surveys, and individual interviews to examine RNs’ overall experiences with falls, the influence of fall prevention on nursing care, and RNs’ perceptions of fall risk factors.^3,4,7–9 In addition, researchers have examined environmental factors that may interfere with RNs’ abilities to prevent falls and factors influencing the implementation of fall prevention programs.^3,10 Others have highlighted the need to understand how nurses deliver fall prevention care to ensure the development of interventions from a nursing perspective.⁸ However, researchers have yet to systematically examine the RN decision-making process related to fall prevention, which is necessary to ensure that hospital fall prevention policies align with nursing workflow and support nursing judgment.

To address this gap in knowledge, the Critical-Decision Method (CDM) was used to systematically explore how RNs make decisions to prevent falls among hospitalized patients. The CDM can be used to understand what a person knows and how a person makes decisions in dynamic, real-life situations.¹¹ The CDM was used to guide in-depth interviews with RNs to discover how they use knowledge and judgment to make decisions about preventing hospital-acquired falls.

Methods

Conceptual Framework

An integrated evaluation framework composed of the Recognition-Primed Decision Model (RPDM) and the Quality Health Outcomes Model (QHOM) was used to guide the interviews and understand RNs’ decision-making process (see Supplemental Digital Content 1, http://links.lww.com/JONA/A770).^12,13 The RPDM is used to explain how experts select a course of action or make decisions. Decision making is based on the expert’s situational awareness and their ability to recognize patterns based on past experiences.¹² Moreover, the QHOM was created to explain the complexities of healthcare quality. Clinical processes or interventions are mediated by patient- and system-level characteristics and do not have a direct effect on outcomes. The reciprocal relationships of the QHOM’s principal constructs (ie, client, intervention, system, and outcomes) are intended to uncover nursing’s contribution to care quality.¹³ These models were integrated using a reflexive qualitative process to evaluate not only the process of decision making (ie, the RPDM) but also the relationships between structural factors and outcomes (ie, the QHOM). This study was approved by the University of Florida institutional review board before commencement.

Critical Decision Method

The CDM is an incident-based cognitive task analysis approach developed to understand naturalistic decision making and was informed by the RPDM.^11,12 The CDM is primarily conducted using case-specific, retrospective interviews and guiding questions to elicit knowledge, cues, influences, and decision-making strategies in dynamic field settings, such as acute care nursing units.¹¹

Sample and Recruitment

Registered nurses were recruited for this study from 8 medical-surgical units in a Magnet^®-recognized, tertiary referral medical center in the southeast region of the United States. To be eligible, RNs needed to be: 1) caring for at least 1 moderate– or high–fall risk patient; and 2) not scheduled to work the following day (because all interviews were scheduled for the following day to minimize recall bias). A study team member explained the purpose, risks, and benefits of the study to RNs who met these criteria. The RNs were compensated with a US$30 gift card for their time.

Data Collection

After participants provided written informed consent, a study team member conducted a semistructured interview based on the CDM with each participant. The goal of the CDM interview was to uncover the cognitive tasks (ie, planning, judgment, decision making) performed by the RN participants as they worked to prevent a fall among their patients.¹¹ Interviews were structured as a 4-phase iterative discussion (Table 1) about the participant’s 12-hour work assignment the previous day. Each interview was audio recorded and conducted in a private conference room. Field notes were collected, and interviews were transcribed and verified for accuracy before analysis.

Table 1.

RNs’ Fall Prevention Decision-Making 4-Phase Interview Process

Interview Phase	Interview Phase Description
Phase 1	RN participant asked to provide a brief description of their patient assignment and a summary of the nursing care they delivered during the previous workday.
Phase 2	With the help of the RN participant, the interviewer drafted a descriptive timeline of the patient care activities that the RN completed during the shift on paper. The timeline was used throughout the interview to clarify the structure of shift (ie, the order of events and activities) and the decisions made by the RN during the shift.
Phase 3	Interviewer probed the RN for additional details about their initial care plan, interventions used to prevent a fall during the shift, and their decision-making process for identifying patients at risk for falling and selecting fall prevention interventions.
Phase 4	Interviewer asked RN to respond to different scenarios to elicit a more complete description of their decision-making process. For example, the interviewer asked, “If the patient had called for assistance out of bed, how would that have impacted the patient’s plan of care?” or “If the patient’s family was not present, how would that have impacted the patient’s plan of care?”

Data Analysis

NVivo 11 (QSR International Inc, Burlington, Massachusetts) was used to organize and manage the transcripts. The RPDM-QHOM integrated evaluation framework was used to establish an initial coding scheme (see Supplemental Digital Content 1, http://links.lww.com/JONA/A770). A consensus process was used to confirm the completeness of the evaluation framework. Data were initially coded using codes based on the RPDM-QHOM framework and emergent codes were produced as these evolved from the data. To establish consistency in the coding process, 2 team members coded the 1st interview together, coded interviews separately, and discussed coding differences. Codes were examined and organized into candidate themes by searching for patterns among the coded data. Initial themes were refined by the research team using a consensus process to yield the final themes. Peer debriefing sessions were held regularly to discuss ongoing analytical interpretations and identify areas in need of further consideration.

Results

Data saturation was achieved with the sample of 12 participants (Table 2 for sample characteristics). Interviews lasted between 60 and 90 minutes. Participants reported caring for a variety of patients, including oncology, transplant, pulmonology, cardiology, neurology, trauma, and surgery patients. The analysis revealed 9 fall prevention themes. Hospital-level factors impacting RN decision making included: 1) compliance with hospital fall prevention policies; and 2) fear of discipline for not adhering strictly to these procedures. Unit-level factors impacting RN decision making included: 3) staffing and workload; and 4) the value that the unit placed on bed alarms to prevent falls. Registered nurse decision making was also influenced by several nurse-level factors, including their 5) trust with patients and families; 6) duty to maintain patient dignity and/or independence; 7) evaluation of the risk of not implementing particular fall prevention interventions versus the benefit of doing so; and 8) overall judgment of the patient. Each of these factors influenced RN decisions related to implementing various 9) fall prevention activities. Table 3 contains supportive quotes for each theme.

Table 2.

Demographic Characteristics of Acute Care Medical/Surgical RNs (n = 12)

Characteristic	n (%)	Mean (SD, Range)
Age		34.4 (13.6, 23-59)
Sex
Male	2 (16.7)
Female	10 (83.3)
Race
White	11 (91.7)
Other	1 (8.3)
Hispanic	1 (8.3)
Highest nursing schooling
Bachelor degree in nursing	11 (91.7)
Associate degree in nursing	1 (8.3)
Works full-time	12 (100)
Years of experience		7.8 (10.6, 0.5-29)

Table 3.

Practice-Based Accounts of RNs’ Fall Prevention Decision Making by Theme

Theme	Quote
1: Falls prevention policy compliance	“If they have a fall score over 45, we stick a fall band on them” (interview 2) “It’s helpful in that if that person’s a fall risk…’You’ve got your yellow band. You’ve got your yellow socks. That identifies it to everybody” (interview 1) “I know why these policies are in place, because some people do not use their judgment” (interview 6)
2: Fear	“It has everybody on edge. It brings everybody alert, but sometimes it’s something you cannot prevent. It does have a lot of people on edge on our unit and I know it’s for a good reason, but at the same time I know that it’s difficult to deal with…the people who have discussed what has happened and how they feel about it, they feel like they have just been shamed…It’s scary. It’s like you already are beating yourself up internally about something and you never want that to happen to anybody” (interview 9) “More often than not, I will put a bed alarm on a high (Morse) fall risk…(because) if I do not, I’m gonna get in trouble” (interview 11)
3: Adequate staffing/patient workload	“I did not have that many patients. I’m like, I’m going to keep the patients I have extra safe today, because I can. I have the capability of going in there, looking in on them, making sure they are okay. I sat by their rooms all day. That was good” (interview 11)
4: Value of bed alarms	“Yeah, at least for us, whenever we hear one going off, everyone runs to make—so if they are getting up, or if they did fall, they’ll have help immediately” (interview 6) “No one wants to get up and deal with it … the alarm fatigue is real. I do not like bed alarms because it creates a false sense of security” (interview 11)
5: Trust	“I felt she wasn’t a fall risk because she was not—I know the patient. I have a prior relationship with her. She is a bilateral amputee. I knew she wasn’t going to make herself roll out of bed…It was a totally trusting relationship. That’s why” (interview 11) “I put the bed alarm on and if they have shown themselves to call for assistance, I’ll turn it off” (interview 2)
6: Duty to preserve dignity/independence	“I was kind of concerned about him getting up…because he has the prosthetic leg, but he really did not want any assistance because he’s independent and he’s been doing this for years. I just let him do it by himself …usually those patients we give, I feel like in general I would say most of us RNs give them, just allow them more independence” (interview 7) “I mean the official thing is you are supposed to be in the bathroom with them. How many people want you to do that?…You’re there with the door cracked, looking, ready to jump” (interview 1)
7: Risk versus benefit	“…they have trapezes so they…can pick up with a bar and shift…if we put the bed alarm on, the second they pull up, the alarm goes off (interview 4)” “She was on a specialty bed. The bed alarm prevents airflow from getting through the—to the patient and creating the therapeutic effect of having a specialty bed. In this case, the benefits of not having the alarm on the bed outweighed the risks of having the bed alarm on the bed” (interview 11)
8: Nurse judgment	“I use more nurse judgment, and I’ll look at the whole picture, the whole person and decide what kind of care they need” (interview 3) “I look at what kind of procedures they have had, and their vitals too, blood pressure… He was having some pain in his leg and his foot. A little bit of numbness…I’m going to watch out for that” (interview 12) “I do not think she was going to move at all. She did not even want to turn in bed when we had to clean her up. She just wanted to not move because she felt sore” (interview 5)
9: Fall prevention interventions	“ Anytime he moved, I was there” (interview 12) “Made sure she had her alarms on. Her bed alarm and her chair alarm on. Not that she would get up, but just in case” (interview 3) “With the high fall risk, you cannot leave them by themselves. You have to be able to see them at all times” (interview 6)

Theme 1: Fall Prevention Policy Compliance

At the time of this study, the fall prevention policy used by the participants prescribed a tiered intervention approach to prevent patient falls. The policy required a set of standardized fall prevention interventions for each level of risk (see Supplemental Digital Content 2, http://links.lww.com/JONA/A771) based on the Morse Fall Scale (ie, low, moderate, and high) (interview 2).¹⁴ Participants discussed performing activities that were required by the fall prevention policy and that certain aspects of the policy were helpful. For instance, if an RN witnessed a patient wearing a high–fall risk band attempting to get out of bed, it was clear that the RN should provide direct assistance to the patient (interview 1). However, the RNs suggested that peers who did not possess good judgment were likely to benefit the most from prescriptive policies (interview 6).

Theme 2: Fear

Participants disclosed fear of being shamed and “getting in trouble” if a patient assigned to them fell. The main source of fear was the postfall huddle that took place after a patient fall (interview 9). During the postfall huddle, the RN would meet face to face in a conference room with multiple hospital administrators to be questioned about the cause of the fall and which required interventions were implemented. This fear resulted in several participants implementing what they thought were unnecessary fall prevention interventions. For example, several participants stated that they implemented bed alarms to avoid “getting in trouble” even though they doubted the effectiveness of the device (interview 11).

Theme 3: Adequate Staffing/Patient Workload

Participants were clear that meeting the needs of a patient at risk of falling required additional time owing to increased demands for bed alarm monitoring and direct assistance with ambulation and patient observation. Because of this increased workload, participants described the need for adequate unit staffing, particularly having enough RNs to decrease the number of patients assigned to each RN. Participants suggested that adequate unit staffing meant they would have the time to implement all necessary fall prevention interventions to keep patients safe (interview 11).

Theme 4: Value of Bed Alarms

Participants had varying perspectives on whether bed alarms are beneficial for preventing falls. When the expectation on the unit was that all staff respond to bed alarms regardless of the patient’s location, participants described bed alarms as helpful because patient falls could be prevented or patients who had already fallen would receive immediate care (interview 6). However, participants explained that on units where there is less staff buy-in for uniformly responding to bed alarms, when an alarm is heard, others tend to walk slowly toward the patient’s room expecting that someone else will respond to the alarm. The fall prevention policy at this hospital only required use of bed alarms when a patient was at high risk of falling, but these participants believed that there was less staff buy-in for uniformly responding to bed alarms when bed alarms are overused (ie, alarm fatigue) (interview 11).

Theme 5: Trust

Participants’ decision making related to fall prevention was motivated by the level of trust they had established with their patient (interview 11). A trusting relationship influenced what fall prevention measures a participant might implement to ensure patient safety regardless of fall risk status. Participants described tailoring fall prevention interventions for those who could be trusted to follow instructions (eg, turning off a bed alarm), compared with patients at risk of falling who were less likely to follow instructions (interview 2).

Theme 6: Duty to Preserve Independence

For some participants, fall prevention decision making was influenced by their duty to preserve the dignity and independence of patients. Participants described deviations from fall prevention policy in order to preserve a patient’s dignity or independence. For example, participants expressed concerns that providing direct observation or assistance might offend patients with a history of being independent despite limitations, such as a patient who received an amputation many years ago, lives alone, and independently cares for himself/herself (interview 7). Participants also expressed concerns about preserving a patient’s privacy during toileting activities while ensuring their safety. For instance, rather than maintaining strict adherence to fall prevention practices through direct observation during toileting activities, participants described staying nearby while patients attended to their private needs (interview 1).

Theme 7: Risk Versus Benefit

Participants expressed benefits that might result from not adhering fully to the fall prevention policy. Primarily, participants discussed situations of weighing the risk of not turning on sensitive bed alarms with other potential benefits to the patient’s health or well-being. For instance, a patient changing his/her position in bed by using a trapeze bar to lift his/her body weight off the bed can activate a bed alarm. Thus, study participants described weighing the risk of a patient falling because of not using a bed alarm with the benefit of a patient being able to reposition themselves using the trapeze bar (interview 4). In addition, placing a bed alarm on top of a circulating air mattress can inhibit air circulation. One participant described weighing the risk of not using a bed alarm with the benefit of using a circulating air mattress for pressure ulcer prevention (interview 11).

Theme 8: Nurse Judgment

Participants highlighted the importance of using nursing judgment and considering the entire physical assessment and history of a patient to determine a tailored fall prevention strategy (interview 11). Participants felt that the fall risk assessment score was not always accurate and that more factors needed to be considered to determine whether a patient was at risk of falling. For instance, participants considered a patient’s physical status, including their physiological condition (eg, overall health, level of deconditioning), symptoms (eg, dizziness), history (eg, recent syncopal episode), recent procedures, and objective and subjective conditions (eg, impaired mobility, desire to move) (interview 12, interview 5). Participants also considered extrinsic factors such as sequential compression devices or chest tubes.

Theme 9: Fall Prevention Activities

Participants discussed implementing a multitude of interventions to prevent patient falls such as providing direct assistance to patients during ambulation (interview 12). In addition, bed alarms were typically described as an activity performed just in case a patient attempted to move without calling for assistance (interview 3). For high–fall risk patients, study participants also reported frequent patient observation rounds and increased surveillance by documenting near the patient’s room and/or arranging for the patient to be closer to the nurse’s station (interview 6). Participants educated patients and families to call for assistance before ambulating and implemented environment interventions, including ensuring: 1) the patient room was clear of obstacles; 2) the patient could reach and use the nurse call light; 3) the appropriate bed side rails were up; and 4) the patient was wearing nonskid socks.

Discussion

While seeking to understand acute care RN’s fall prevention decision-making processes, new details were uncovered related to the effectiveness of bed alarms: bed alarm effectiveness may depend on how other staff members on the unit use these devices. In addition, system features such as strict policies could be directly impacting RN morale because of a fear of being shamed or reprimanded.

Studies examining bed alarm effectiveness for preventing hospital-acquired falls have been inconclusive.^15,16 These results could be attributed to alarm fatigue or a perceived false sense of security on the part of the RN.¹⁷ Through this study’s evaluation of RNs’ fall prevention decision-making process, it was determined that bed alarm effectiveness could be impacted by how other staff members on the unit respond to bed alarms (ie, unit culture as a barrier to technology effectiveness). In a study of RNs’ and nursing assistants’ decision making related to the use of safe patient handling and mobility technology (eg, patient lift), researchers found that unit culture was a barrier to technology adoption and use.¹⁸ Nursing administrators should consider approaches for ensuring unit buy-in (eg, involving unit staff early, soliciting feedback, gaining unit support) if they choose to implement bed alarms as a fall prevention activity.

Participants in this evaluation emphasized the importance of considering nurse judgment along with a fall risk assessment score when determining a patient’s risk. Researchers have found that RN clinical judgment can be as accurate as a fall risk assessment tool.^19,20 In fact, the use of clinical judgment to tailor fall prevention interventions has been shown to significantly reduce the incidence of falls.¹⁹ Although participants expressed value for nursing judgment and nurse-tailored patient care plans, they also shared a fear of being shamed or reprimanded for not adhering strictly to the fall prevention policy. It is possible that nursing administrators are unaware that nurses perceive postfall huddles as punitive instead of inquisitive, but this finding is consistent with those reported in a recent qualitative study: RNs often feel scrutinized, shamed, and fearful because of falls, especially as a result of the investigations that are conducted after the incident.⁸ This fear could be resulting in a negative impact on nurse morale. Nursing administrators should carefully consider how fall prevention policies are being presented to nurses (eg, if there is still room for nurses to use their judgment) and consider approaches for making postfall huddles less intimidating and more supportive for nurses. In addition, nursing administrators could consider exploring nurse moral and attitudes within their organization because they may be unaware of nurse fearfulness.

Limitations

Participants were recruited from medical-surgical units within 1 hospital. It may be that fall prevention decision making differs on other unit types such as intensive care or maternal/child units. However, as previously noted, this study included RNs who cared for a diverse set of patients (ie, variation in primary diagnosis). A 2nd limitation is related to the homogeneity of the sample, which varied slightly by race, sex, and education level. Although saturation was reached with this sample, it is possible that a heterogeneous set of participants could reveal a more dynamic set of RN fall prevention decision-making themes. Lastly, the fall prevention policy and culture within the hospital may not be like that of other hospitals. However, this hospital did follow an evidence-based, multifactorial fall prevention program based on a standardized risk assessment tool.

Recommendations for Nurse Administrators and Other Future Implications

This systematic evaluation of RNs’ fall prevention decision-making process revealed numerous themes that influenced the implementation of fall prevention interventions. Participants highlighted shared understanding and commitment among staff when using technology interventions and fear of consequences if they decided to deviate from hospital policy. To improve fall prevention efforts, nursing administrators could work with frontline nurses within their organizations to understand: 1) whether nurses think they have the autonomy to use their professional judgment when deciding on fall interventions; 2) nurse attitudes toward the adoption and use of assistive technologies such as bed alarms; and 3) whether nurses are confident that their participation in postfall huddles will not be punitive. Nursing administrators should encourage the development of transformational leadership qualities among frontline clinical leaders. A transformational leader is empathic and can foster creativity and a supportive environment in which nurses are encouraged and motivated to participate in decision making and innovation.²¹ Future research should explore nursing leadership and staff perceptions about the goal(s) of postfall huddles, the use of assistive technologies in clinical care, and RN autonomy. Specifically, do nursing administrators, frontline clinical leaders, and nursing staff have shared goals when conducting a review of a fall incident? And, are frontline staff RNs equal partners in deciding to adopt and use assistive technologies and in tailoring fall prevention interventions based on the unique needs of patients?