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Implementing Patient Falls Education in Hospitals: A Mixed-Methods Trial

1 School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, VIC 3086, Australia; [email protected] (H.H.); ua.ude.ne[email protected] (L.S.); [email protected] (D.J.)

2 Northern Health, Melbourne, VIC 3076, Australia

Debra Kiegaldie

3 Holmesglen Institute and Healthscope, Monash University, Melbourne, VIC 3800, Australia; [email protected]

4 The Victorian Rehabilitation Centre, Healthscope, ARCH La Trobe University, Melbourne, VIC 3086, Australia

Louise Shaw

Dana jazayeri, anne-marie hill.

5 Western Australian Centre for Health & Ageing, School of Allied Health, The University of Western Australia, Perth, WA 6009, Australia; [email protected]

Meg E. Morris

Associated data.

The data presented in this study are available in Supplementary file D.

Patient education is key to preventing hospital falls yet is inconsistently implemented by health professionals. A mixed methods study was conducted involving a ward-based evaluation of patients receiving education from health professionals using a scripted conversation guide with a falls prevention brochure, followed by semi-structured qualitative interviews with a purposive sample of health professionals involved in delivering the intervention. Over five weeks, 37 patients consented to surveys (intervention n = 27; control n = 10). The quantitative evaluation showed that falls prevention education was not systematically implemented in the trial ward. Seven individual interviews were conducted with health professionals to understand the reasons why implementation failed. Perceived barriers included time constraints, limited interprofessional collaboration, and a lack of staff input into designing the research project and patient interventions. Perceived enablers included support from senior staff, consistent reinforcement of falls education by health professionals, and fostering patient empowerment and engagement. Recommended strategies to enhance implementation included ensuring processes were in place supporting health professional accountability, the inclusion of stakeholder input in designing the falls intervention and implementation processes, as well as leadership engagement in falls prevention education. Although health professionals play a key role in delivering evidence-based falls prevention education in hospitals, implementation can be compromised by staff capacity, capability, and opportunities for co-design with patients and researchers. Organisational buy-in to practice change facilitates the implementation of evidence-based falls prevention activities.

1. Introduction

A key role of health professionals who work in hospitals is to educate patients about falls prevention [ 1 ]. Patient education is an essential part of falls prevention, given that up to 20–30% of hospital incidents are falls [ 2 ]. Falls prevention education aims to improve patient knowledge about falls and falls risks, and to teach patients and their carers about falls mitigation [ 3 ]. By educating patients, health professionals can help to minimise the mismatch between perceived risk and actual risk of falling whilst in hospital [ 4 ].

While recent studies highlight the potential of patient education to reduce falls, most trials have employed research staff to deliver the intervention rather than health professionals [ 2 , 5 , 6 ]. These trials were often carried out in sub-acute or rehabilitation wards, with few studies focusing on the acute setting [ 5 ]. In hospitals, patient education is usually delivered by nurses and allied health professionals [ 7 , 8 ]. Despite the evidence showing that educating patients can reduce hospital falls [ 9 , 10 ], nurses and allied health professionals arguably face barriers to delivering patient education in everyday practice [ 11 ]. Time constraints mean that patient education is not always implemented early. As there is a higher risk of falls in the first week of a hospital admission [ 12 , 13 ], it is important for health professionals to prioritise the delivery of evidence-based education very soon after admission.

One strategy to assist clinicians to implement evidence-based practice is to provide them with a guide for delivering falls education in the form of a scripted conversation. Scripted conversation guides have been used to educate patients in different healthcare contexts, such as advanced care planning [ 14 ], pre-operative care [ 15 ], and post-discharge falls prevention [ 16 ]. Scripted guides provide clinicians with a standardized and consistent method of delivering education whilst still tailoring the content to individual needs. This approach is favoured by hospital patients [ 11 ]. Another strategy is to provide patients with evidence-based falls prevention brochures [ 9 , 17 ]. The advantage of brochures is that patients can access falls prevention information at any time and as many times as needed. A combination of education modes has been shown to be more effective than relying on a single modality for delivering falls prevention education [ 10 , 17 ]. Combining a scripted conversation delivered by a health professional coupled with a patient fall prevention brochure, is arguably a robust method for delivering falls prevention education in hospitals.

Despite the evidence showing the benefits of patient falls education [ 2 , 17 ], the implementation of evidence into routine hospital practice to prevent falls and associated injuries remains challenging [ 18 , 19 , 20 ]. There can be barriers to translating evidence into practice such as cost, inconvenience, lack of confidence and skills, and social and environmental context [ 18 , 21 ]. While there have been some studies investigating falls research implementation barriers [ 22 , 23 , 24 ], few have done so in the context of hospital falls education research.

We conducted a mixed-methods study that aimed to compare usual care with health professional delivery of an interactive patient falls education intervention using a scripted conversation coupled with an evidence-based patient education brochure. Usual care included a hospital-wide policy on falls prevention strategies such as safe footwear, physical activity, assistive devices, environmental modifications, management of cognitive impairment, diet and medication reviews, and clinician and patient education that was informal and unstructured. We also aimed to identify enablers, barriers, and strategies to improve the implementation of falls education delivered by nurses, allied health professionals, and other hospital staff.

2. Materials and Methods

2.1. study design.

This was a mixed methods study involving a quantitative analysis of a hospital-based patient education intervention with follow up semi-structured qualitative interviews of health professionals involved in delivering the intervention. This design was chosen as the qualitative phase would help to interpret and build upon the results of the quantitative data [ 25 ]. For the quantitative analysis, patients were randomised to an experimental group or control group. We used a computer random number generator to assign the hospital wards to receive either usual care or additional falls prevention education. Health professionals who worked on the experimental group ward delivered the intervention. They received education and training prior to implementation [ 26 ]. The control ward patients received usual care. Health professionals working in the control ward did not receive any additional education or training. It was not possible to blind the research assessors; however, the researchers were not involved in supervising health professionals or the care of patients, thereby reducing risk of bias. There were no associations between the participants and the research team.

For the qualitative interviews, a purposive sample of staff members who were involved in coordinating and delivering the patient education were interviewed to investigate barriers, enablers, and recommended strategies for implementation.

2.2. Ethical Considerations

This research was supported by an Australian NHMRC partnership grant (GNT1152853) and was registered on the Australian New Zealand Clinical Trials Registry (ACTRN12621000430831). Ethics approval was granted by La Trobe University (HEC21023).

2.3. Study Population and Setting

Participants for the quantitative analysis were patients in either a medical or surgical ward of a private Australian acute care hospital. The wards were randomised to be either a control ward (usual care) or an intervention ward (receiving a scripted conversation about falls prevention and a brochure). Recruitment occurred over a 5-week period in 2021. Patients were excluded from the study if they were not medically stable, had cognitive impairment, or were not able to communicate in English.

For the qualitative study, nurses and allied health professionals were eligible to participate if they attended the health professional education training session and delivered the education intervention. Managers were recruited if they were involved with the study, such as assisting with coordinating the trial processes. Recruitment occurred 2 months after the end of the quantitative component. This delay was due to limited availability of staff, awaiting ethics amendment approval, and staff shortages associated with the COVID-19 pandemic.

2.4. Intervention

The falls prevention intervention was delivered by nurses and allied health professionals and consisted of a face-to-face scripted conversation about how to prevent falling and a standardized evidence-based hospital falls prevention brochure in addition to usual care. The conversation was based on the principles of the Safe Recovery Program [ 6 , 27 , 28 ] and was simplified to focus on clarifying falls prevention information, teach-back methods, and goal setting. The intervention aimed to empower patients to take responsibility for their own fall prevention, while being feasible for ward staff to deliver given existing time constraints. It followed the quality metric tool used in Heng et al. [ 17 ], which was adapted from the 4P model of educational principles. The learner and teacher characteristics, learning activities, and outcome evaluation were considered. The intervention was designed to be delivered within 24 h of patient admission to the ward and included having follow up conversations with the patient to reinforce education and check on attainment of goals previously set by the patient. The intervention underwent several iterations following feedback obtained from a panel of clinicians, experts in falls prevention, and consumers.

One week prior to implementation, nurses and allied health professionals attended a 1 h training session in person or through videoconferencing. The training was provided by a researcher (LS) who was an experienced clinical educator. The training session included provision of the latest evidence on patient education for falls prevention, pre-recorded vignettes of simulated delivery of the intervention, and small group discussion. The full description of the training can be found in Shaw et al. [ 26 ]. A training session was recorded for staff to access online if they were not able to attend in person. Consent was gained at this stage for a follow-up interview with each health professional.

2.5. Data Collection

Quantitative data were collected from patients using a survey that included demographic data and self-reported responses to seven items on a five-point Likert scale. The survey was based on an instrument by Khong et al. [ 29 ] and evaluated patient knowledge about falls, self-perceived risk of falls, falls behaviour change, as well as patient views on the learning experience ( Supplementary File S1 ). Eligible patients completed the pre-test survey at the bedside with a researcher (H.H. or R.L.) once written consent was provided. The same researchers were responsible for collecting post-test data 1–2 days after participants received the intervention. The same procedure was carried out in the control ward.

For consenting health professionals, individual semi-structured telephone interviews were conducted by a researcher (D.K.) at their convenience. Telephone interviews were necessary due to the COVID-19 pandemic restrictions at the time [ 30 ]. Two separate interview schedules were designed after expert advice and discussions between research team members and experienced qualitative researchers. One schedule was for health professionals who were directly involved with patient education ( Supplementary File S2 ), while the other schedule was for health professional managers who did not deliver the intervention but were associated with the implementation process of the first phase ( Supplementary File S3 ). An independent transcription service transcribed each interview. Participants were de-identified and assigned a number in each transcript.

2.6. Data Analysis

For the quantitative phase, distributions and measures of central tendency were used to describe the demographic make-up of each patient group. Patient data were subjected to descriptive analysis where appropriate.

A qualitative descriptive approach with thematic analysis was used to identify themes and sub-themes from the interviews [ 31 , 32 , 33 ]. For the qualitative data, template analysis using a coding template to represent themes from the data was used to identify patterns and ideas from the interview transcripts [ 34 , 35 ]. The main themes pertained to perceptions and experiences of participants in the context of the research questions and interview schedules [ 31 ] Two researchers (H.H., L.S.) independently analysed and coded the qualitative interview data. The interviews were focused on barriers, enablers, and recommended strategies for implementation of patient falls prevention education. Findings were discussed via video-conferencing meetings. A third researcher (D.K.) was consulted to achieve consensus if there were differences in opinion. Coded data were presented in spreadsheets and tables. Quotes were chosen to support final themes and sub-themes.

3.1. Quantitative Data

Over five weeks, 122 hospital patients were approached with 85 declining to consent as they had no interest in participating in the study or were planned for discharge the following day. In total, demographic data and pre-test surveys were collected from 37 participants (intervention n = 27; control n = 10). The full details of patient characteristics can be found in Table 1 . There were 16 women in the patient intervention group (59.3%) and 5 women in the control group (50.0%). The mean age of the intervention group was 15 years greater than the control group (intervention 75.3 SD 16.56, range 36–96; control 60.2 SD 22.26, range 28–94).

Patient participant characteristics.

+ data from one participant missing. * includes digestive system disorders, infections, cancer, and renal disorders. ** other than orthopaedic surgeries.

In the intervention group, the mean proportion of patients who received the intervention on the ward each day was 15.3% (0.153 SD 0.06, range 0.074–0.267). On average, 22.1% of patients on the ward each day were reported to be cognitively impaired as per ward records (0.221 SD 0.05, range 0.133–0.308). For the 27 patients in the intervention group, 25 provided pre-test data and only 3 provided post-test data. One consented to providing pre- and post-test data while two completed the post-test survey without completing the pre-test survey beforehand. Within the control group, post-test data were collected from eight participants with an average of 1.625 days (SD 0.7) between pre- and post-test surveys. Due to the inability to obtain sufficient paired responses (pre and post), inferential statistics could not be calculated. Throughout the trial period, which occurred during the COVID-19 pandemic, the research team implemented several strategies to improve intervention delivery and staff engagement in the project and data collection. This included increasing the presence of researchers on the ward to support staff and respond to questions, engaging senior leadership, reminders during handover, and input from executive staff. The average number of interventions carried out doubled, however, this was not sustained past week four.

3.2. Qualitative Analysis

Seven individual interviews were conducted with health professionals over three weeks. This was the full complement of consenting hospital staff. The participants were enrolled nurses ( n = 3), a registered nurse ( n = 1), physiotherapist ( n = 1), assistant nurse unit manager ( n = 1), and an executive staff member with a background in nursing ( n = 1). The average duration of the interviews was 20.6 min (SD 4.97).

From an analysis of views expressed by the interviewed participants, three broad themes about implementation emerged ( Table 2 ): (i) barriers to implementing falls education; (ii) enablers for implementation of falls education; and (iii) recommended strategies to improve implementation. Quotes supporting each theme has been included in Supplementary File S4 .

Summary of themes.

3.3. Barriers to Implementing Falls Education

Several interviewees indicated that the patient status affected patient engagement, with a significant proportion of patients on the intervention ward having cognitive impairment or being too medically unwell to participate. Many of them felt that they were not able to deliver the falls education intervention if the patient was cognitively impaired, and unable to understand the information. Others noted that some patients had language barriers or did not recognise their risk of falls and therefore declined to engage with the clinician.

“…the biggest barrier was probably the cognitive impaired patients, anyone with a language barrier” (P5, enrolled nurse.)

Staff attitudes were also recognised by participants as contributing to reduced engagement with the implementation process such as previous unsuccessful falls prevention measures, patient-related barriers, or workload demands. As a result, there was a perception that staff were reluctant to carry out the intervention. A lack of confidence or knowledge was also acknowledged as being a barrier.

“Like, some felt like it’s just a time-consuming thing without real benefit for our class of patients”. (P2, registered nurse.)
“the nursing staff’s knowledge base of that particular subject would determine how successful, and obviously, their ability to engage with a different level and different variety of patients, really, depending on their condition…” (P6, executive.)

Despite reporting strong interprofessional teamwork prior to the trial, interviewees acknowledged that there was limited collaboration in relation to falls education. Intra- (within profession) and interprofessional (between professions) communication and collaboration were encouraged during the clinician training, however, participants noted that there was no specific discussion among staff during the trial. Staff may therefore not have felt the need to focus on further collaboration due to the pre-existing interprofessional relationship.

“…overall on the ward, there might be—possibly like there might not be the best sort of communication across all the other disciplines, and that’s where you might run into trouble”. (P1, physiotherapist.)

Some commented that there was a lack of staff input into designing the intervention and the trial process, which may have contributed to staff being unsure about the expectations and procedures. Some of the interview participants felt that if staff were consulted beforehand, they could have highlighted issues with ward processes or be better prepared in how to appropriately implement the patient education. These issues could have been remedied prior to the start of the trial, thus improving implementation outcomes.

“There wasn’t any consultation with the staff of how would be the best way to deliver this, and no real conversation regarding what were the expectations of the staff going into this”. (P3, enrolled nurse.)

The modelling scenarios used in the training session were thought to be helpful by those interviewed but they felt it did not fully encompass realistic settings. They perceived that the scenarios did not accurately reflect barriers such as language barriers and time constraints, which resulted in creating challenges when attempting to adapt the scripted conversation to these situations.

“…in a real-life situation when the nurse is working…the dynamics change. You know when you’re watching [the training]…you’re doing this thing, and that’s what you have to do. Where, in a realistic, real-life work situation where you have five patients to look after, this one is buzzing, maybe this one need toileting… In the middle of an education program someone can buzz, …there can be an emergency call in another room, and the alarms are going off. You need to attend to that. You need to end your education pathway to [work through it]. So it wasn’t really practical in the real-life situation”. (P2, registered nurse.)

Other barriers reported included time constraints, a perception by some staff that there was limited leadership support and organisational management underpinning patient education, and few processes to support implementation of the research evidence into clinical practice. Lack of staff time was cited as a major barrier to delivering patient falls education. Interviewees agreed that time was limited on the ward due to staffing ratios, level of care required for patients, and existing high workloads. Some participants reported not receiving enough information prior to the trial, which led to them feeling unsupported and at times frustrated. Others highlighted the importance of leadership engagement to improve ward staff commitment to the patient education process. Several of the staff participants identified process limitations such as a breakdown in top-down communication and uncertainty in the delegation of responsibilities that may have contributed to implementation difficulties.

“We know that during this period, from what I recall, the manager…had some leave…There was some probably not-ideal communication there, we could have probably tightened up on that. And so, there was some areas where our communication probably wasn’t as tight as it should have been, and probably some other issues going on there, personal issues”. (P6, executive.)

Inconsistencies in ward processes were also perceived to be an issue. For example, one nurse commented that the intervention relied on patients receiving falls prevention brochures at admission, however, this had ceased previously due to COVID-19 restrictions. This was perceived to have had an impact on the delivery of education to patients and their families.

“…there are directives that come down from the top that are made without any, what feels like, without much input from us on the bottom line” (P7, enrolled nurse.)

3.4. Enablers for Implementation of Falls Education

Fostering patient empowerment with falls prevention was one factor that motivated the interviewed staff to implement evidence-based falls education. They perceived that the scripted dialogue and falls brochure engaged, educated, and empowered patients to prevent falling. Additionally, they felt that the patient falls prevention education intervention involved patients in decision-making, which allowed patients to have some autonomy over the process. As a result, they felt patients were more likely to adhere to falls prevention strategies. This was helpful in building a positive relationship between the patient and staff. For the health professional participants, knowing that the trial was an evidence-based intervention was a motivating reason to implement the patient education despite existing barriers. They considered evidence-based practice to be an essential part of healthcare and trusted that the intervention would be effective in preventing falls.

“for me, being able to be involved in something like this, …putting into practice having evidence-based care, as a clinician that’s personally important. I think the development of evidence-based care is essential to nursing. I mean, it’s [the only way] we get anywhere really. So, it was good…knowing that that’s what it was”. (P3, enrolled nurse.)

Other views on enablers for implementation related to existing intra and interprofessional collaboration, consistent reinforcement of falls education, having a structured and embedded approach to falls prevention, and the use of modelling scenarios during training. The interview participants agreed that there was a strong existing collaborative relationship between nurses and allied health professionals. Examples were provided of allied health professionals engaging with nursing staff about falls prevention prior to the commencement of the trial. Participants also reported a strong intraprofessional (within profession) communication and collaboration.

“I didn’t have a lot of discussions about this program, but allied health is always discussing with us nurses about the mobility and falls risk and so forth of the patient”. (P5, enrolled nurse.)

Interviewees also found that having a consistency of falls education provision across and within professions enhanced implementation. Reinforcement of the same message from the healthcare team was cited as a key feature to encourage clinicians to implement the intervention.

“…we were all educated about it, around about the same time, so we…were on the same page, which I think was more or less a protective factor in terms of implementing the work” (P3, enrolled nurse.)

Formalising and structuring the intervention and having resources available was thought to be helpful in delivering the patient education. The resources perceived to be of value included the printed guides for staff and the recording of the training session. One nurse identified that incorporating the intervention into usual care helped with implementation. They also appreciated the scenarios that were presented during the training session. Watching the scenarios helped them understand how the intervention was to be delivered, how to respond to patients, and it developed their confidence in carrying out the scripted conversation.

“it was like a real-life scenario, hearing it actually out loud and sort of being role played, yeah, it showed how the conversation can flow and it showed how it can work”. (P7, enrolled nurse.)

A strong enabler for implementation of the intervention expressed by participants was the support from senior staff. Several participants reported that it was motivating when they received frequent reminders and encouragement from senior staff to implement the intervention.

“I know that when we started a shift we were reminded about the program, so that was very good to remind [us]”. (P5, enrolled nurse.)

3.5. Recommended Strategies to Improve Implementation of Patient Falls Education

Several recommendations were proposed by the staff interviewed to improve implementation outcomes. Ensuring accountability, both between staff and towards patients, was one strategy raised. Some felt that by being accountable for patients in their care, staff would naturally carry out interventions that were beneficial to patients. It was also suggested that staff be accountable amongst themselves by supporting each other with frequent check-ins and reminders.

“…it’s about knowing your patient and being accountable you start to know your patient. And then if you know your patient, then you start to sort of go to that next step and think about ways to improve their care”. (P1, physiotherapist.)

Another participant proposed focusing further on intra- and interprofessional collaboration about the intervention. Some examples given were to have discussions and specific conversations about the intervention during handover sessions and between groups. This would increase awareness among staff and improve implementation. Engaging staff and providing support was another strongly recommended strategy. Suggestions included involving staff in identifying barriers, advising staff how the intervention adds value to their work, informing staff about the positive changes arising from implementation of the intervention, and incentives. Some suggested increased support from research staff and further training and education for clinicians would help. A few interview participants felt that implementation outcomes would improve if the intervention was embedded into usual practice. By making it a part of their daily routine, staff would find it easier to carry out falls education. Initiating the intervention early and implementing it throughout the patient’s stay may assist as well.

“We have some standard protocols that needs to be done while the patient is getting admitted, so just as part of the admission process. I think that might make a habit of them to just do it” (P4, assistant nurse unit manager.)

In line with the barriers previously identified, some interviewees strongly believed that stakeholder input on the design of the intervention along with leadership engagement and support would greatly improve feasibility of delivery and implementation outcomes. Strong leadership engagement and support may also improve communication amongst ward staff and encourage uptake and adherence. Having hospital systems and policies aimed at supporting the implementation of patient education was another suggested strategy. Organising regular meetings and audits was also considered to be a helpful way of ensuring improved implementation processes.

“…clearly, once we’ve got the buy-in from the executive, and then there needs to be the buy-in from the manager to be on the same page, in terms of what we’re trying to achieve and what the actual issues are, and the involvement in the actual research project, and to really have that buy-in, that we need to give this a go. And then, of course, then it’s disseminated amongst the ANUMs [associate nurse unit managers] and then filtered down to the other staff”. (P6, executive.)

4. Discussion

Despite the strong body of literature showing that person-centred and interactive patient falls prevention education can be a powerful determinant of the frequency of hospital falls [ 2 , 9 , 17 ], the behaviour change associated with health professionals adapting their routine clinical practice to implement evidence-based patient education can be challenging to achieve [ 36 , 37 , 38 ]. Even though steps were taken in the current study to ensure effective delivery of the evidence-based falls prevention intervention, only a small proportion of hospital patients received the intervention as part of this trial. Running the trial during the COVID-19 pandemic was one factor that might have contributed to this issue.

Our experience of implementation challenges is not uncommon. Other studies have also investigated barriers to falls prevention implementation programs [ 22 , 23 , 24 ]. The themes raised in this study were similar to the findings of Ayton et al. [ 22 ], Semin-Goossens et al. [ 23 ], and O’Connell and Myers [ 24 ]. Of note, the importance of leadership engagement to achieve the implementation of evidence into practice was highlighted [ 22 , 23 , 24 ]. The qualitative data from health professionals in the current study provided valuable insights into the enablers and barriers of implementation of evidence-based falls education.

Time constraints and heavy workloads were a major barrier to health professionals delivering falls education within hospital wards in the current trial. This finding was in agreement with several studies in acute and sub-acute settings [ 39 , 40 ]. Health professionals often face a heavy workload, particularly in acute care hospital settings [ 41 , 42 ]. This may have been exacerbated by the COVID-19 pandemic in this current study. Even though falls prevention is talked about as a priority for most health professionals [ 8 ], a lack of time is consistently cited as a barrier to carrying out evidence-based practice [ 39 , 43 ]. For example, a study by McKenzie et al. [ 44 ] showed that the pressure of the work environment and heavy workloads were reported as a barrier in implementing an intervention for creating a safety culture. Carrying out the intervention was considered an additional task rather than being a core part of the role of health professionals. This was reflected in the qualitative data where a lack of time and increased workloads were reported to impact on intervention delivery.

Reduced engagement from some leaders was another perceived barrier to the implementation of evidence-informed patient education. While health professionals acknowledged support from senior staff as an enabler, they identified that further communication and support from leaders could have improved implementation outcomes. When senior members of an organisation are supportive of change, staff are more likely to carry out evidence-based interventions [ 39 , 43 , 44 ]. Yost et al. [ 45 ] noted that having supportive organisational leaders can lead to more successful outcomes. By engaging leaders, further barriers could be overcome, such as identifying pre-existing limitations in institutional processes. Similarly, including stakeholder input when designing patient falls education resources was a recommendation that arose from this trial. This is in agreement with O’Cathain et al. [ 46 ], which identifies stakeholder input as crucial when developing health interventions. A strong consumer engagement allows for a better designed trial and intervention that meets the needs of stakeholders, leading to more feasible interventions and effective implementation outcomes [ 47 ].

Several factors can affect the implementation of research into clinical practice [ 36 , 37 ]. Behaviour change has been shown by Michie et al. [ 48 ] to be key. They advised that individuals need to have capability, motivation, and access to opportunities for effective behaviour change. A theoretical domains framework can also be utilised to target specific domains within each component of the behaviour change wheel [ 48 , 49 ]. For example, to improve an individual’s reflective motivation, the intervention may need to address health professional beliefs about their capabilities and consequences, or their intentions and goals [ 49 ]. Applying these behaviour change theories will allow for a better design of implementation interventions [ 50 ]. In addition, educational models such as the 4P model of educational design [ 51 ], which emphasizes stakeholder engagement and management support, knowing the context of the learning environment, and having a full appreciation of learner and teacher characteristics prior to implementation, may also assist with implementation.

Some of the ways that health professionals can be supported to implement evidence into practice include training, education, and modelling from the leadership team. Our study determined that receiving this training can foster motivation to implement strategies to empower patients to prevent falling whilst in hospital. Creating an awareness about falls risk factors and preventative measures should be reinforced in health professional training to encourage implementation [ 22 , 28 ]. A recent study by Provvidenza et al. [ 52 ] highlighted that training delivered at an organisational level can be effective in improving knowledge translation in hospitals. The nature of knowledge translation and implementing research is known to be complex [ 20 ]. Promoting accountability among individuals as well as between the organisation and the workforce was a recommendation that was raised in our current study. This was in agreement with other studies conducted in the context of fostering a safety climate in hospitals [ 44 , 53 , 54 ]. Falls and associated injuries are a persistent safety challenge in hospitals globally [ 1 , 10 ].

There were limitations of the current study. Only patients without cognitive impairment were included because they needed to be able to read and respond to patient education pamphlets. For future trials, cognitively impaired patients could be included. Strategies such as repetition, rephrasing, and frequent positive reinforcement can be considered when delivering education to the cognitively impaired [ 17 , 55 ]. Training health professionals about these strategies by using role play or working with simulated patients can also be contemplated [ 56 ]. In addition, we did not quantify the effects of the intervention on falls risk, rates, or injuries. Only acute wards participated and sub-acute or rehabilitation wards may have different outcomes given the longer length of stay. The similarities and differences of the wards and how the context of the ward may have shaped interviewees insights were not analysed. Another limitation was the short timeframe for data collection. If the study could be conducted over a longer period, staff may have had more time to understand and follow implementation processes leading to more patient data. The COVID-19 pandemic was a major limitation to data collection. Due to the restrictions imposed by the pandemic, interviews with staff needed to be conducted by telephone and staff training sessions were modified to incorporate social distancing and personal protective equipment. Using personal protective equipment and masks may have impacted on program delivery because comprehension challenges could have been misidentified as a language or cognitive barrier.

5. Conclusions

Ensuring that health professionals consistently deliver evidence-based interventions in hospitals is an ongoing challenge. Time constraints, heavy workloads, and limited engagement from staff in leadership roles can sometimes be barriers to the rapid translation of research evidence into clinical practice. Supportive organisational leaders, engaging stakeholders in research, and promoting accountability among staff may lead to better implementation outcomes and enhance the effectiveness of patient falls prevention education.


We thank Petrina Adams and Rosalie Lui for their valuable assistance in organising this trial. We also thank the staff and patients who generously gave their time to participate in this research.

Supplementary Materials

The following supporting information can be downloaded at: https://www.mdpi.com/article/10.3390/healthcare10071298/s1 , Supplementary File S1: Pre- and Post-intervention survey; Supplementary File S2: Interview schedule for clinical staff; Supplementary File S3: Interview schedule for managers; Supplementary File S4: Participant quotes.

Funding Statement

This research was funded by NHMRC, partnership grant number GNT1152853.

Author Contributions

Conceptualization, H.H., M.E.M., D.K., A.-M.H., L.S. and D.J.; methodology, H.H., M.E.M., D.K., A.-M.H., L.S. and D.J.; formal analysis, H.H., D.K. and L.S.; investigation, H.H. and L.S.; writing—original draft preparation, H.H.; writing—review and editing, H.H., M.E.M., D.K., A.-M.H., L.S. and D.J.; supervision, D.K. and M.E.M.; project administration, D.K. and M.E.M.; funding acquisition, D.K. and M.E.M. All authors have read and agreed to the published version of the manuscript.

Institutional Review Board Statement

The study was conducted in accordance with the Declaration of Helsinki, and approved by the Ethics Committee of La Trobe University (protocol code HEC21023).

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study.

Data Availability Statement

Conflicts of interest.

The authors declare no conflict of interest. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results.

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Background: Patient falls are a serious problem in a rehabilitation unit. Although patient falls have been described in the healthcare literature for more 60 years, and many risk assessment tools have been developed, the rate of falls in hospitals in Japan has remained unchanged for the last 8 years. A previous study reported that about 50% of patients in rehabilitation estimated their fall risk lower than that estimated by their nurses. We believe that patients in rehabilitation tend to overestimate their ability to perform ADLs. Aim: To identify discrepancies between patients’ and nurses’ estimates of patients’ ability to perform activities of daily living (ADL) and clarify any relationship between the discrepancies and patient falls. Methods: Participants comprised 82 patients (42 men) admitted to a rehabilitation unit in Osaka, Japan from July to December of 2017. Patients and their nurses answered the same questionnaire about patients’ ability to perform ADL. The questionnaire was developed based on the Functional Independence Measure (FIM) and administered at admission, at 1 month after admission, and at discharge. Participants were classified into the overestimating group and the accurately estimating/underestimating group, and groups were compared using Wilcoxon rank-sum tests. Results: The mean age of participants was 76.4 years. At admission, approximately 72% of participants estimated their own ability to perform ADL higher than did the nurses. The percentage of overestimating participants dropped to 30% at discharge. Fifteen of the participants experienced a fall; all were in the overestimating group. The ADL Discrepancy and fall-assessment scores for these 15 participants were significantly higher than those of other participants. Conclusions: There are discrepancies between patients’ and nurses’ estimates of patients’ ability to perform ADL and had important significance for assessing their risk of fall. And minimizing the discrepancy may support the prevention of falls.

Accidental Falls , Rehabilitation , Risk Assessment

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1. Introduction

The majority of older people with rehabilitation need suffer from cerebrovascular or orthopedic diseases, and therefore undergo rehabilitation to improve their ability to perform activities of daily living (ADL). However, older people with these diseases are more vulnerable to falls owing to their disease-related loss of physical function [1] . Risk factors for falls in the rehabilitation phase may be categorized as internal (e.g., age, gender, history of falls, disease-related symptoms, physical function, cognitive function, and medication) or external (e.g., physical obstacles, noise, and illumination) [2] . In addition, patients with chronic conditions who are in the rehabilitation phase must learn to accurately assess their own physical functioning, and healthcare providers must take measures to prevent them from falling.

2. Background

Japan is the world’s fastest-aging society. Thanks to the remarkable development of medical care in recent years, the mortality rate for cerebrovascular disease is decreasing yearly [3] . However, the number of patients living in the community with the effects of cerebrovascular disease is increasing, as is the number receiving services under the long-term care insurance system. It has been reported that most patients with cerebrovascular disease face the effects of their disability through experiences in which they are unable to perform ADL, or they suffer a fall, or when they interact with others who have the same disease; it takes a certain period of time for these patients to accept their disability [4] . However, although many studies have shown that most rehabilitation patients’ falls occur early in their hospitalization, no studies have focused on patients’ pre-disability perceptions [5] . It has also been reported that about 30% of patients who suffer from a fall-induced orthopedic disease and are admitted to an acute-care unit will fall again after being discharged. The main reason for this is the typical living environment that is peculiar to Japanese houses, which includes small steps and narrow corridors inside the houses [6] . Therefore, it is recommended that instead of being discharged from an acute-care unit immediately, patients should be transferred to a rehabilitation unit where they can perform intensive rehabilitation to improve physical function, have their discharge destination environment adjusted, and review recommendations for life after discharge. Importantly, the number of patients in the rehabilitation unit of many medical institutions continues to increase. There is little research available in this area because most studies on fall risk that consider the patient’s perspective tend to focus on falls during the acute phase of treatment rather than during the rehabilitation phase [7] .

One study about patients with acute conditions that solicited the patient’s perspective was conducted by Radecki [8] ; their qualitative investigation aimed to identify patient perspectives on fall prevention in acute care and to help design patient-centered strategies. Twelve patients shared their thoughts on their own fall risks, showing that awareness of fall, acceptance/rejection to their own disability, meaning, feelings, and personal planning were important to them. On the basis of their analysis, Radecki emphasized that nurses must build relationships with their patients to understand their needs [8] .

The results showed that nurses and patients agreed on the causes of falls when the patient was assisted, but they differed in their perceptions of the causes when the patient was unassisted and independent and did not seek assistance from the nurse [9] .

Another study, by Barmentloo, found that acute patients were more positive than were patients with chronic conditions about the knowledge and skills of healthcare professionals. This suggests that patients in the chronic phase may be less positive about healthcare professionals [10] .

Fall prevention assessment in chronic rehabilitation units is often conducted using the same fall-risk assessment tools that are used in acute care [11] . However, assessments using these tools find most patients of rehabilitation units to be at higher risk of falling ( i.e. , high sensitivity but low specificity) [12] . Furthermore, it has been reported that about 50% of patients undergoing rehabilitation underestimate their own risk of falling compared with their nurse’s estimate [2] .

These findings suggest the importance of tools and educational methods for promoting fall-risk assessment that consider the perspectives of patients in chronic rehabilitation units. In addition, patients in the rehabilitation phase tend to overestimate their own physical abilities as they regain their ADL as rehabilitation progresses.

This suggests that in chronic rehabilitation units it is necessary to clarify differences between patients’ self-assessments and nurses’ assessments in relation to common items for assessing ADL levels. Therefore, in this study we compared patients’ and nurses’ estimates of abilities to perform ADL on the day of admission, one month after admission, and the day before discharge. We then investigated the relationship between the results and falls. The differences between patients’ and nurses’ ratings of patient ADL levels over the course of their hospitalization were used to develop a new fall-risk assessment tool that includes self-assessment for hospitalized patients.

We aimed to identify discrepancies between patients’ self-estimates and nurses’ estimates of patients’ ability to perform ADL at rehabilitation units, to clarify any relationship between the discrepancies and patient falls, and to develop a scale to identify discrepancies in estimates.

4.1. Design

A quantitative observational study.

4.2. Sampling and Recruitment

Participants were all patients capable of having a daily conversation who were admitted to a rehabilitation unit in Osaka, Japan, from July to December 2017. In the 50-bed study unit, patients undergo rehabilitation for 2 - 3 hours per day. There were 57 falls among the 17,338 patients in the unit in 2018. Clinical staff had received previous training on using the Functional Independence Measure (FIM) to assess patients’ physical function on admission.

4.3. Inclusion and Exclusion Criteria

Patients with dementia, higher brain dysfunction, or a Mini Mental State Exam (MMSE) score [13] below 14 were excluded, following the advice of a neurologist who is honorary director at this hospital. Four participants were discharged within 1 month, three were transferred because their conditions deteriorated, and 12 were not discharged within the study period. In this study, the adapted FIM questionnaire was completed by both patients and nurses, while most international measurement tools solicit only medical staff responses. We developed the new questionnaire under the supervision of a head nurse, a physical therapist, and an occupational therapist. In our analysis of the questionnaire responses, Cronbach’s alpha was 0.927 for patients (n = 82) and 0.964 for nurses (n = 82), indicating that the questionnaire has strong validity and internal consistency.

4.4. Data Sources/Collection

Study researchers verbally explained the survey method to the 21 participating nurses who were working in study unit and had more than 3 years of clinical experience. Study staff assisted patients who had difficulty reading or writing due to symptoms such as paralysis or visual impairment; to avoid guiding or leading the answer, only the reading was done without explanation about the questions and options. On the day of admission, a nurse handed the questionnaire to the patient in bed, and the patient completed it. The nurse then on the same day estimated the patient’s ability to perform ADL using the same questionnaire.

4.5. Instrument with Validity and Reliability

The instrument we developed is based on the FIM [14] , which is widely used in rehabilitation units to estimate patients’ functioning and disability levels. It has 18 items in two major categories (motor and cognition), with each item scored on an ordinal scale from 1 to 7. The score reflects the level of assistance needed to perform ADL: a score of 1 indicates that the patient requires full assistance; a score of 7 indicates total independence. This tool has been shown to have good reliability and prognostic potential at admission, and FIM scores are inversely related to fall rates [15] [16] .

Patients’ fall-assessment scores were also recorded with the fall-risk assessment tool in use at the study hospital. This tool, developed by a physician, an occupational therapist, a physical therapist, and a nurse, has 15 items with a total possible score of 77 points. Items cover the patient’s age, physical dysfunction, mental dysfunction, medication, and excretion. A score of 1 - 9 indicates the patient is at low risk of falling, 10 - 19 indicates a medium risk, and 20 - 77 indicates a high risk. Our modified questionnaire was administered a second time 1 month after admission and a third time the day before discharge. Each patient’s self-estimate and the corresponding nurse’s estimate had a total possible score of 42 points (each item = 1 - 7 points).

4.6. Data Analysis

The difference between the nurses’ estimates and the patients’ self-estimates was defined as the ADL Discrepancy, with a larger ADL Discrepancy score reflecting greater discrepancies between the patient’s and the nurse’s estimates. A positive score indicated that the patient was overestimating their ability to perform ADL, and a negative score indicated that the patient was underestimating their ability. A score of zero indicated perfect agreement.

Participating patients were classified into two groups: the overestimating group (ADL Discrepancy score > 0) and the accurately estimating/underestimating group (ADL Discrepancy score ≤ 0). Participants were also classified into the falling group or the not-falling group based on whether or not they fell during the study period, using the standard and common-sense definition of a fall as “an incident in which a patient suddenly and involuntarily comes to rest upon the ground or surface lower than their original situation” [17] . The study groups were compared using t-tests and Wilcoxon rank-sum tests. Microsoft Excel and JMP statistical software were used for data aggregation and analysis. The level of significance was set at less than 0.05.

4.7. Ethical Considerations

This study was approved by the Research Ethics Committee of the participating hospital (Approval number: 2017-03). Written informed consent was obtained from all participants.

Of the 105 patients admitted to the rehabilitation unit during the study period, 23 (21.9%) were excluded because of an MMSE score lower than 14 points. Eighty-two patients (mean age 76.4 years; 42 men) remained for inclusion in the analyses. Participant characteristics by group (overestimating group and accurately estimating/underestimating group) are presented in Table 1 . Approximately 72% of the participants were in the overestimating group. The overestimating group also had significantly higher fall-assessment scores (p = 0.043) than the other group. The only nonsignificant difference was observed between the discrepancy between patients’ and nurses’ estimates of patients’ ability to perform ADL and MMSE, but patients with low MMSE scores tended to overestimate their physical function.

Most participants had self-assessment scores of 31 - 40 points on admission and 41 - 42 points on discharge. The majority of participants received assessment scores from their nurses of 11 - 20 points on admission and 41 - 42 points on discharge. Most participants received fall-assessment scores of 20 - 29 points on admission and <19 points on discharge.

The percentage of participants in the overestimating group dropped from 72% at admission to 30% at discharge. Not only did the nurses’ estimates of 87% of participants in the overestimating group rise, but the self-estimates of 18% participants also fell at 1 month after admission. The number of participants who accurately estimated their ability to perform ADL gradually increased, reaching 65% on discharge.

There were 15 patients who experienced a fall, nine of whom fell within 1 month of admission. The characteristics of participants in the falling and not-falling groups are presented in Table 2 . The falling group demonstrated significantly higher ADL Discrepancy scores (p = 0.048) and fall-assessment scores (p = 0.042) than the not-falling group. Notably, all participants in the falling group were in the overestimating group. There were no significant differences between the two groups for the other items. Four participants had fall-assessment scores (7, 10, 13, and 19) that were lower than the overall average (21.7 points).

Table 1 . The overestimating group and the accurately/underestimating group on admission day and 1 month later: A comparison of estimates.

*p < 0.05 (Wilcoxon rank-sum test).

Table 2 . Comparison of the falling group and the not-falling group on admission.

6. Discussion

The present study investigated discrepancies between patients’ self-estimates and nurses’ estimates of patients’ ability to perform ADL and found that, at admission, patients in the rehabilitation unit tended to overestimate their ability to perform ADL. This discrepancy was correlated with the rate of falls among patients.

Patients receiving rehabilitation may overestimate their ADL because of a lingering pre-injury body image or a body image from an earlier stage of their disease. While nurses may, by contrast, underestimate their patients’ abilities, in the present study the likelihood of this occurring was low because our questionnaire had high internal consistency, and the participating nurses were familiar with the FIM.

All patients who fell during the study had on admission overestimated their ability to perform ADL. Patients who overestimated their ability to perform ADL experienced significantly higher fall rates than those who accurately estimated/underestimated their ADL. Moreover, patients who overestimated their ability had significantly higher fall-assessment scores. Interestingly, Yamada [18] reported a marked lack of body image accuracy in older people who had experienced falls. They showed, furthermore, that the accuracy of a person’s body image reflects their physical function, and that this factor is also useful for assessing fall risks. Thus, those with an inaccurate body image were likely at higher risk for falls; addressing ADL Discrepancy may be one strategy for enhancing fall prevention.

Notably, by the end of hospitalization, the self-estimates of most of our participants in the overestimating group approximately matched their nurses’ estimates. This may have been because patients improved their physical function through rehabilitation, and during hospitalization learned more about their physical disability and about behavior commensurate with their abilities. It therefore suggests that rehabilitation unit admission is a meaningful period for addressing ADL Discrepancy and preventing falls. When a patient who overestimates his or her own physical function falls, the fall may cause not only secondary injuries and deterioration of physical function, but also induce a loss of self and a fear of falling again. In particular, fear of falling has been shown to limit one’s ADL and to reduce quality of life, which is likely to lead to a vicious cycle of further decline in physical function and strength, and increased risk of falling [19] [20] . Fear of falling can also negatively affect walking speed and balance, which in turn increases the risk of falling and hinders rehabilitation progress [21] [22] . Therefore, preventing falls is an essential component of effective rehabilitation.

It is also difficult to judge the risk of falls using only our questionnaire, but although our findings suggest that ADL Discrepancy is a risk factor for falls, no existing assessment tool includes this item. Therefore, the creation of new tools that include ADL Discrepancy items, which can also be used in combination with existing tools, will lead to the development of better fall prevention.

In our study most falls occurred, and ADL Discrepancy was highest, within the first month following admission; after that period, ADL Discrepancy declined. Arguably, the degree of patients’ overestimation of their ability to perform ADL and the frequency of their falls has a parallel relationship. Indeed, our finding that most falls occurred during the first month after admission was consistent with the results of previous studies [5] [23] .

Because patients tended to overestimate their own ADL levels and were more likely to fall shortly after admission to rehabilitation, the first month following admission should be viewed as the most crucial period for fall prevention, and specific care should be taken to that end. Given the gradual narrowing of the gap between patients’ and nurses’ assessments of ADL after the initial 1-month period, admission to a rehabilitation unit clearly can reduce the risk of falls. Thus, nurses should collaborate and plan patient care with physical therapists not only during rehabilitation but also during daily unit life to help patients develop their own accurate body image and learn to perform activities safely within their current physical function levels. Additionally, because patients with impaired cognitive function tend to overestimate their abilities, it is necessary to assess cognitive function as well as physical function, and to perform a comprehensive risk assessment for each patient at the admission stage.

As populations age, the number of frail and vulnerable older people also increases. As a result, the number of patients who will be unable to return home immediately after acute treatment is also expected to increase, as will consequently the number of patients who wish to be admitted to rehabilitation units. To ensure that patients can live safely both during their hospital stay and after discharge, it is necessary not only to improve their physical functions but also to keep them involved throughout the rehabilitation process, including by soliciting and considering their thoughts and wishes. We recommend that nurses support patients in multiple ways, beginning at the time of admission, so when they are discharged there are minimal gaps between patient and nurse assessments of patients’ ADL.

7. Conclusion

This study found consistent discrepancies between patients’ self-estimates and nurses’ estimates of patients’ ability to perform ADL in a rehabilitation unit. Approximately 70% of patients overestimated their physical abilities on admission; this group included every patient who fell during rehabilitation in the study period. Therefore, minimizing the discrepancy between patients’ and nurses’ estimates of patients’ ability to perform ADL may support the prevention of falls.


We would like to acknowledge all the support of all the patients and nurses who participated in this research.

Conflicts of Interest

The authors declare no conflicts of interest.

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Lynne Lohfeld

Canadian journal of public health = Revue canadienne de santé publique

To identify risk factors for falls and injuries among seniors living in a long-term care facility. Case-control study of 335 residents living at St. Joseph&#39;s Villa, Dundas, Ontario. Cases were defined as residents who fell between July 1, 1996 and June 30, 1997; controls were those who did not fall. To identify risk factors for injury, cases were defined as those with completed incident injury forms and controls as those without. The most important risk factors for falls included: having fallen in the past three months; residing in a secured unit; living in the facility for two or more years; having the potential to cause injury to others; and having an illness, disease or behaviour that may cause a fall. The most important risk factor for injury among those who fell was altered mental state. The risk factors identified may be helpful to those planning falls prevention initiatives within long-term care settings.

Risk factors for falls and injuries in a long-term care facility in Ontario

Kirsten Moore , Elizabeth Cyarto , Emma Renehan , Marcia Fearn , Emma Lea

2012, Geriatric Nursing

Outcomes from the Implementation of a Facility-Specific Evidence-Based Falls Prevention Intervention Program in Residential Aged Care

Kim Delbaere

2008, The Medical journal of Australia

To develop screening tools for predicting falls in nursing home and intermediate-care hostel residents who can and cannot stand unaided. Prospective cohort study in residential aged care facilities in northern Sydney, New South Wales, June 1999-June 2003. 2005 people aged 65-104 years (mean +/- SD, 85.7+/-7.1 years). Demographic, health, and physical function assessment measures; number of falls over a 6-month period; validity of the screening models. Ability to stand unaided was identified as a significant event modifier for falls. In people who could stand unaided, having either poor balance or two of three other risk factors (previous falls, nursing home residence, and urinary incontinence) increased the risk of falling in the next 6 months threefold (sensitivity, 73%; specificity, 55%). In people who could not stand unaided, having any one of three risk factors (previous falls, hostel residence, and using nine or more medications) increased the risk of falling twofold (sensitivi...

Development and validation of fall risk screening tools for use in residential aged care facilities

Rachel Harrington

2004, Age and Ageing

Falls prevention in residential care homes: a randomised controlled trial

teresa martins

Portuguese Journal of Public Health

Introduction: To identify factors predictive of falls and enable appropriate management of fall risk it is necessary to understand the behaviour and health conditions of older adults living in nursing homes. Objective: This study had two main objectives. The first was to find significant predictors for falls in older adults living in nursing homes. The second main goal was to build a predictive model to find the best predictors for falls. Methods: Out of 56 nursing homes with the same legal statute, 25 agreed to participate. The sample was randomly selected and only the independent or slight/moderately dependent participants were included in the study (n = 325). Results: There was a mean of 1.47 ± 0.99 falls (range from 1 to 7) per resident in nursing homes. By using the t test and odds ratio analysis, ten factors related to falls were identified. Through the binary logistic regression, a model was tested identifying four robust predictors: static balance, resorting to emergency ser...

Risk Factors Associated with Falls among Nursing Home Residents: A Case-Control Study

Leonie Oldmeadow

Four‐item fall risk screening tool for subacute and residential aged care: The first step in fall prevention

2010, The Medical journal of Australia

To test the effectiveness of using a full-time project nurse to assist residential aged care facilities in using evidence-based approaches to falls injury prevention. Cluster randomised controlled trial involving 5391 residents in 88 aged care facilities in the Hunter and Lower Mid North Coast areas of New South Wales. Residents were followed for 545 days or until death or discharge. Data were collected from July 2005 to June 2007. Employment of a project nurse to encourage best-practice falls injury prevention strategies during the 17-month intervention period. Monthly data about falls, falls injury and falls injury prevention programs; audit of hospitalisation for fractured neck of femur. Despite significant increases in the provision of hip protectors and use of vitamin D supplementation in both intervention and control facilities, there was no difference in the number of falls or falls injuries between the intervention and control groups, nor a reduction in falls overall. There ...

A cluster randomised controlled trial to prevent injury due to falls in a residential aged care population

mohammed masoud

Falls are responsible for considerable morbidity, immobility, and mortality among older persons, especially those living in nursing homes. Many different causes and several risk factors that predispose clients to falls have been identified. Multiple risk factors of fall among elderly are considered, including socio-demographic, psychological and medical factors, medication use, and environmental hazards. The study aims to assess the risk factors of falls among elderly clients at geriatric homes. Research design: A descriptive design was used in carrying out this study. Setting: The present study was conducted in 4 geriatric homes: Dar El-Safa, Dar El-Marwa, Dar Hedia Barakat1 and Dar Hedia Barakat2. Sampling: A purposive sample of 111 clients was chosen randomly. Tools: Two tools were designed to collect data. 1) An interviewing questionnaire to assess client’s socio-demographic characteristics, intrinsic risk factors, and health status. 2) An observational checklist to assess their...

Risk Factors Regarding Fall Among Elderly Clients at Geriatric Homes

Jesús Cuesta

2013, BMC Geriatrics

Factors associated with falls among older adults living in institutions

Gemma Walker

2015, Clinical Rehabilitation

Objective: To explore the feasibility of implementing and evaluating the Guide to Action Care Home fall prevention intervention. Design: Two-centre, cluster feasibility randomized controlled trial and process evaluation. Setting: Purposive sample of six diverse old age/learning disability, long stay care homes in Nottinghamshire, UK. Subjects: Residents aged over 50 years, who had fallen at least once in the past year, not bed-bound, hoist-dependent or terminally ill. Interventions: Intervention homes ( n = 3) received Guide to Action Care Home fall prevention intervention training and support. Control homes ( n = 3) received usual care. Outcomes: Recruitment, attrition, baseline and six-month outcome completion, contamination and intervention fidelity, compliance, tolerability, acceptance and impact. Results: A total of 81 of 145 (56%) care homes expressed participatory interest. Six of 22 letter respondent homes (27%) participated. The expected resident recruitment target was achi...

The Falls In Care Home study: a feasibility randomized controlled trial of the use of a risk assessment and decision support tool to prevent falls in care homes

Bengt Winblad

2007, Journal of Clinical Nursing

Falls and fall risk among nursing home residents

2009, Scandinavian Journal of Caring Sciences

Falls in somatic and dementia wards at Community Care Units

Pamphile Mengue

2007, International Journal of Older People Nursing

Prevalence of falls with minor and major injuries and their associated factors among older adults in long-term care facilities

Divna Kekus

2017, Medical review

Introduction. Falls and fall-related injuries are common in the geriatric population and may be associated with significant morbidity and mortality. The aim of this study was to determine differences in the incidence of falls and risk factors for falls between the community-dwelling and institutionalized elderly people. Material and Methods. The cross sectional study was conducted in the period from May 1, 2015 to December 1, 2015, including 300 community-dwelling elderly people and 110 nursing home residents. The research instruments were a sociodemographic questionnaire, Mini nutritional assessment, Katz index, and Lawton scale. Results. During the previous 12 months, at least one fall was reported in 17.1% of the total number of respondents. The incidence of falls was higher among nursing home residents (c2 = 13.550; p = 0.001). The risk factors for falls were multifactorial. Community-dwelling elderly suffered from urinary incontinence more frequently compared to nursing home re...

Incidence of falls in the elderly population

Laurence Rubenstein

1994, Annals of Internal Medicine

Falls in the Nursing Home

purushottam thapa

1996, Journal of the American Geriatrics Society

Injurious Falls in Nonambulatory Nursing Home Residents: A Comparative Study of Circumstances, Incidence, and Risk Factors

Jack Needleman

2012, Clinical Nursing Research

Incidence and Cost of Serious Fall-Related Injuries in Nursing Homes

Tariq Masud

Preventing falls and injuries in care homes

agne jakavonyte-akstiniene

2016, CBU International Conference Proceedings

BACKGROUND: Falls are a major public health problem, especially in the elderly. Of people who suffer falls, 20- 30% experience mild to severe injuries. Timely assessment of risk factors can prevent some of these falls occurring.PURPOSE OF STUDY: To assess the falls risks factors of patients in nursing departments.METHODS: The study was conducted January to September, 2015 in a Lithuanian long-term care and treatment hospital. The Morse Fall Scale was used for assessment of falls risk, which were evaluated within 48 hours and then after one month of admission to the hospital.RESULTS: The study involved 177 respondents. After one month of admission to the hospital, 129 participants took part in the survey. During the first stage of the study, the difference in falls between the age groups and falls risk was statistically significant (p = 0.019). In addition, statistically significant differences (p = 0.004 and p = 0.000) were found between the patients’ cognitive impairment, falls wit...

Falls’ Risk Analysis of Older Patients in Nursing Departments: One Month Study

Sarah Hilmer

2011, Therapeutic advances in musculoskeletal disease

Frail older individuals living in residential aged care facilities (RACFs) have impaired physical function compared with to older people living in the community. In residents of RACFs, we aimed to produce sex-specific means and empirical norms of objective physical function measures to ascertain whether these measures are predictors of falls. Data were extracted from a large cohort study investigating fall and fracture rates in RACFs in the Northern Sydney Health Area, Australia. Study participants (n = 602, 70.9% female) were recruited from 51 RACFs. Cohort means (±standard deviation) for females were for grip strength (GS) 16.8±5.3 kg, simple reaction time (RT) 384±154 ms, walking speed (WS) 0.56 ±0.20 ms(-1), balance category (B) 3.8±1.1 and sit to stand category (STS) 3.6±0.5. For males, means were for GS 28.8±7.8 kg, RT 335±150 ms, WS 0.62±0.22 ms(-1), B 4.1±1.1 and STS 3.7±0.5. Means of B and STS decreased significantly over the 1-year study period for males and females (p &lt...

Physical functioning measures and risk of falling in older people living in residential aged care facilities

Canadian Geriatrics Journal

Background Half of Canadians living in long-term care (LTC) homes will fall each year resulting in consequences to independence, quality of life, and health. The objective in this study was to analyze factors that contribute to, or are protective against, falls in Canadian LTC homes. Methods We analyzed of a retrospective cohort of a stratified random sample of Canadian LTC homes in Western Canada from 2011–2017. We accessed variables from the RAI–MDS 2.0 to assess the association of the dependent variable “fall within the last 31–180 days” with multiple independent factors, using generalized estimating equation models. Results A total of 28,878 LTC residents were analyzed. Factors found to increase the odds of falling were other fractures (OR 3.64 [95% confidence interval; CI 3.27, 4.05]), hip fractures (OR 3.58 [3.27, 3.93]), moderately impaired cognitive skills (OR 2.45 [2.28, 2.64]), partial support to balance standing (OR 2.44 [2.30, 2.57]), wandering (OR 2.31 [2.18, 2.44]). Co...

Factors Associated with Falls in Canadian Long Term Care Homes: a Retrospective Cohort Study

Anne Tiedemann

2009, American Journal of Physical Medicine & Rehabilitation

The Effect of Enhanced Supervision on Fall Rates in Residential Aged Care

Linda Coventry

Background: Injurious falls in hospital patients are threat to patient safety which can result in a financial burden on the patient’s family and health care services. Both patient specific and environmental and organisational factors are associated with injurious hospital falls. It is important to continuously analyse the factors associated with the severity of falls which can inform the implementation of any fall preventive strategies. This study aims to identify risk factors associated with the severity of falls in hospitalised adult patients in Western Australia.Methods: This study involved a retrospective analysis of hospital inpatient falls records extracted from the hospital’s Clinical Incident Database. Falls clinical incidents were reviewed and analysed from May 2014 to April 2019.Results: There were 3705 complete reported cases of falls with the average age of the patients was 68.5±17.0 years, with 40.2% identified as female. Gender, activity at time of fall and height of f...

Factors Associated With Severity of Falls In Adult Hospital Patients: A Retrospective Audit

2006, Preventive Medicine

Validity of the STRATIFY risk score of falls in nursing homes

2020, Applied Nursing Research

Background: Falls and fall-related injuries remain an ongoing and serious health problem in older adults. Many clinical and environmental factors have been implicated in falls and recurrent falls, including sleep disturbances, sensory deficits, balance problems, incontinence, comorbid conditions, and certain categories of medications. We undertook this study to determine if there was an association between these factors and falls or recurrent falls in older adult residents of an aging in place community. Methods: Our retrospective case-control study compared residents who did and did not fall in an aging in place community, as well as those who experienced recurrent versus single falls in a single year. Results: A total of 50 residents met the criteria for inclusion in this study, with 30 participants (60%) having experienced one or more falls during the observation period. Of the 30 participants who fell, 21 (70%) experienced more than one fall in a single year. Variables associated with falls included marital status and bowel incontinence; variables associated with recurrent falls included self-reported sleep difficulty, balance with sitting to standing and surface-to-surface transfer, use of a walker, and use of antidepressant medications. Discussion: Our study supports the existing nursing research that falls, and recurrent falls are the result of multiple, interrelated factors. Further research is needed into preventative measures for both falls and recurrent falls, particularly in the context of aging in place.

Characteristics of falls and recurrent falls in residents of an aging in place community: A case-control study

Clint Moloney

2014, The JBI Database of Systematic Reviews and Implementation Reports

Assessing the risk of falls among community dwelling older adults: a best practice implementation project

Péricles Reche

2016, Revista da Rede de Enfermagem do Nordeste

Risk of falls and associated factors in institutionalized elderly

Tatjana Bulat

2010, Journal of the American Medical Directors Association

Fall Prevention and Injury Protection for Nursing Home Residents

Nancye Peel

2011, Canadian Journal on Aging / La Revue canadienne du vieillissement

Epidemiology of Falls in Older Age

Marcia Bento Moreira

2007, Revista Latino-Americana de Enfermagem

The association between nursing diagnoses and the occurrence of falls observed among eldery individuals assisted in an outpatient facility

Ali Dadgari

2019, International Journal of Health Studies

The Incidence of Fall and Past History of Falling in Aged Hospitalized Patients

Bangonsri Jindawong

2013, The Southeast Asian journal of tropical medicine and public health

Falls among the elderly can lead to disability, hospitalization and premature death. This study aimed to determine the factors related to falls among community dwelling elderly. This case-control study was conducted at the Samlium Primary Care Unit (SPCU), Khon Kaen, Thailand. Cases were elderly individuals who had fallen within the previous six months and controls were elderly who had not fallen during that same time period. Subjects were taken from elderly persons registered at the SPCU. The sample size was calculated to be 111 cases and 222 controls. Face to face interviews were conducted with subjects between May and June, 2011. The response rate was 100%. On bivariate analysis, the statistically significant factors related to falls were: regular medication use, co-morbidities, mobility, depression, cluttered rooms, slippery floors, unsupported toilets (without a hand rail), sufficient exercise, rapid posture change and wearing slippers. When controlling for others significant f...

Factors related to falls among community dwelling elderly

Tammy Hoffmann

2013, Clinical Interventions in Aging

Circumstances of falls and falls-related injuries in a cohort of older patients following hospital discharge

Ian Cameron

2003, Journal of the American Geriatrics Society

Differing Risk Factors for Falls in Nursing Home and Intermediate-Care Residents Who Can and Cannot Stand Unaided

Piyatida Junlapeeya

2004, Applied Nursing Research

Falls in a community of older adults: findings and implications for practice


2019, Revista Brasileira de Geriatria e Gerontologia

Objectives: to identify the demographic and clinical profile, context of risk and the occurrence of falls among institutionalized elderly persons; analyze the association between the classification of risk of falling using the Brazilian version of the Morse Fall Scale and the occurrence of falls in such individuals. Method: A cohort study was performed in two long-stay institutions in the city of Porto Alegre, Brazil. The sample consisted of 193 elderly persons. Descriptive and inferential statistics (Chi-squared and Fisher tests) were used for analysis. Results: The occurrence of falls was associated with hearing impairment, hand grip strength, Katz Index score, degree of dependence according to Collegial Board Resolution 283/2005 and risk of falls according to the MFS-B. Conclusion: Falls have multifactorial causes, which makes it important to identify the agents that contribute to their occurrence, as it is known that institutionalization significantly increases the risk of falli...

Analysis of risk factors for falls among institutionalized elderly persons

Teresa Williams , Katherine Birkett

Evaluation of a falls prevention programme in an acute tertiary care hospital

Katherine Berg

2002, The Journals …

Methods. The purpose of this investigation was to determine the risk factors for nonfallers versus fallers (1+ falls), and for nonfallers/one-time fallers versus recurrent fallers (2+ falls). All participants (N = 2304) in this study were receiving home care services from 10 community-based ...

Risk factors for falling among community-based seniors using home care services

Wendy Watson

2011, New South Wales Public Health Bulletin

Prevalence, circumstances and consequences of falls among community-dwelling older people: results of the 2009 NSW Falls Prevention Baseline Survey

Hossein Fakhrzadeh

2015, Archives of Gerontology and Geriatrics

Predicting risk of the fall among aged adult residents of a nursing home

Mark Hudson

2008, Journal of Patient Safety

Risk Factors and Injury Associated With Falls in Elderly Hospitalized Patients in a Community Hospital

Atena Editora


Falls are a recurring problem in the elderly, with physical and psychological consequences for the elderly, the family and society. Goals: 1-identify risk factors for the occurrence of falls in the elderly; 2- evaluate practices and behaviors to prevent falls in the elderly who attend a day care center. Method: analytical cross-sectional observational study, carried out in a day care center in the metropolitan region of Lisbon to answer the question: What are the risk factors, practices and behaviors of the elderly living in the community to prevent falls? Approval by the Ethics Committee. Sample consisting of 13 elderly people who attend day care. A questionnaire was applied with: 1) sociodemographic characteristics, 2) degree of dependence in activities of daily living (Barthel Index), cognitive status (Mini Mental State Examination), 3) risk factors, 4) Morse Falls Scale and 5) Scale of practices and behaviors of the elderly in the prevention of falls. Results: The elderly have a mean age of 80.92 years (SD= 6.96), are male (53.8%), with 4 years of schooling (84.6%), are widowed (69.2%) and live alone (61.5%). All have deficits in balance, have pathologies at the level of the cardiovascular system (92.3%) and musculoskeletal (69.2%), with moderate dependence with the same percentage (38.5% respectively), none of them have cognitive deficits. They have low risk and high risk of falling with the same percentage (38.5% respectively), independent. In communication practices and behaviors, 46.2% reported that doctors and nurses never warn them about the risk of falling. In Safety Practices and Behaviors, 38.5% do not check if the bathroom floor is slippery before using it. However, they have safety practices in the management of the surrounding space [(choice of the best preventive measures (53.8%), organization of the room space for travel (84.6%) and removal of obstacles from the bedroom and hallway (69.2%)] to prevent falls. Conclusions: The study revealed several risk factors for the occurrence of falls in the elderly (advanced age, sensory deficit, balance deficit, pathology and medication). In practices and behaviors for communication, there is a deficit on the part of health professionals to inform about the risk of falling, while in the practices of safety behaviors of the elderly, there is a deficit in the prior observation of the state of the floor in safety practices in the space where move. The data underscore the importance of a multiprofessional, community-based intervention to train the elderly in behaviors that prevent the risk of falling.


Bernard-simon Leclerc , Lise Goulet

2010, Revue d'épidémiologie et de santé publique

Evidence linking home hazards to falls has not been well established. The evidence-based approach to fall-risk assessment in longitudinal studies becomes difficult because of exposures that change during follow-up. We conducted a cohort study to determine the prevalence of hazards and to resolve whether they are linked to the risk of falls among 959 seniors receiving home-care services. A home hazards assessment was completed at entry and every six months thereafter using a standardized form. The adjusted (for a number of confounding factors) relationship between home hazards and falls was estimated using a survival model taking into account updated time-varying exposures and multiple events. Falls leading to a medical consultation were examined as a secondary outcome, hypothesized as a measure of severity. Home environmental hazards were found in 91% of homes, with a mean of 3.3 risks per individual. The bathroom was the most common place for hazards. The presence of hazards was si...

Relationship between home hazards and falling among community-dwelling seniors using home-care services


  1. (PDF) Quantitative Research in Nursing Science

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    A quantitative study conducted in clinical and surgical units of a teaching hospital in Southern Brazil. The sample comprised 358 patients. Data

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