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Quantitative falls risk assessment in elderly people: results from a clinical study with distance based timed up-and-go test recordings

Andreas Ziegl 1,2 , Dieter Hayn 1,3 , Peter Kastner 1 , Kerstin Löffler 4 , Lisa Weidinger 4 , Bianca Brix 5 , Nandu Goswami 5 and Günter Schreier 1,2

Published 9 December 2020 • © 2020 The Author(s). Published on behalf of Institute of Physics and Engineering in Medicine by IOP Publishing Limited Physiological Measurement , Volume 41 , Number 11 Citation Andreas Ziegl et al 2020 Physiol. Meas. 41 115006 DOI 10.1088/1361-6579/abc352

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1 AIT Austrian Institute of Technology GmbH, Graz, Austria

2 Institute of Neural Engineering, Graz University of Technology, Graz, Austria

3 Ludwig Boltzmann Institute for Digital Health and Prevention, Salzburg, Austria

4 Albert Schweitzer Institute for Geriatrics and Gerontology, Geriatric Health Care Centers Graz, Graz, Austria

5 Physiology Division, Otto Loewi Research Center, Medical University of Graz, Graz, Austria

Andreas Ziegl https://orcid.org/0000-0003-1948-567X

Dieter Hayn https://orcid.org/0000-0003-1822-9033

Nandu Goswami https://orcid.org/0000-0002-6704-0723

Günter Schreier https://orcid.org/0000-0003-3724-4255

  • Received 14 July 2020
  • Accepted 21 October 2020
  • Published 9 December 2020

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Objective : A third of people over 65 years experiences at least one fall a year. The Timed Up-and-Go (TUG) test is commonly used to assess gait and balance and to evaluate an individual's risk of falling. Approach : We conducted a clinical study with 46 older participants for evaluating the fall risk assessment capabilities of an ultra-sound based TUG test device. The fall protocols over a period of one year were used to classify participants as fallers and non-fallers. For frailty evaluation, state-of-the-art questionnaires were used. Fall recordings were compared to six TUG test measurements that were recorded in fallers and non-fallers. Main results : TUG test data were available for 39 participants (36 f, age 84.2 ± 8.2, BMI 26.0 ± 5.1). Twenty-three participants did fall at least once within the fall screening period. We fitted two different regression and probability models into a region of interest of the distance over time curve as derived from the TUG device. We found that the coefficient of determination for Gaussian bell-shaped curves ( p < 0.05, AUC = 0.71) and linear regression lines ( p < 0.02, AUC = 0.74) significantly separated fallers from non-fallers. Subtasks of the TUG test like the sit-up time showed near significance ( p < 0.07, AUC = 0.67). Significance : We found that specific features calculated from the TUG distance over time curve were significantly different between fallers and non-fallers in our study population. Automatic recording and analysis of TUG measurements could, therefore, reduce time of measurements and improve precision as compared to other methods currently being used in the assessments of fall risk.

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1. Introduction

Frailty and falls are the main causes of morbidity and disability in elderly people. Around one third of persons over 65 years fall at least once a year (Tinetti and Kumar 2010 ). Several studies have shown that 40% of falls in nursing homes are related to posture changes from sitting to standing (Rapp et al 2012 , Goswami 2017 ). According to previous studies, the strongest risk factors for falling are previous falls, the strength of a person, gait characteristics, balance impairments and the usage of specific medications (Tinetti and Kumar 2010 , Tinetti et al 1988 ).

The Timed Up-and-Go (TUG) test is a commonly used tool for evaluating elderly individuals' risk of falling (Panel on Prevention of Falls in Older Persons, American Geriatrics Society and British Geriatrics Society 2011 , Kang et al 2017 ). It measures the time in seconds taken by an individual to stand up from a standard chair, walk for 3 meters, turn, walk back to the chair, and sit down. It includes a variety of functional mobility tasks (TUG subtasks), such as standing up, walking, turning, and sitting down. The TUG test has been recommended to assess gait and balance (Herman et al 2011 ). Numerous authors have investigated TUG ability of assessing the fall risk. (Killough 2006 ) mentioned the ROC curve for the previous fall analysis which demonstrated an area under the curve (AUC) of 0.64 to differ between fallers and non-fallers and (Andersson et al 2006 ) showed in 105 participants that TUG can be used to evaluate which patients tend to fall in order to carry out preventive measures (positive predictive value [PPV] = 59%). Nevertheless, several studies looking at the total TUG time (that is, time from standing up until sitting down again), however, have shown limited ability to predict falls (Barry et al 2014 ). Kojima et al ( 2015 ) monitored 259 participants over 6 months and concluded that the ability of TUG to predict future falls is limited with an achieved AUC of 0.58. Viccaro et al ( 2011 ) reported that the TUG test did not add predictive ability rather than using gait speed for fall classification in 457 over 1 year (both AUCs < 0.7). Also, Beauchet et al ( 2011 ) mentioned in their review that TUG is discussible, and that the predictive ability is limited. Nocera et al ( 2013 ) recommended including covariates like disease severity, quality of life and cognitive abilities to increase the number of correctly classified TUG test samples. TUG tests with such covariates (a secondary task) like a cognitive task and TUG with a manual task like physical exercises have been evaluated by different authors. Virtuoso et al ( 2014 ) performed a study with 82 physically active old people over 12 months and achieved an AUC of 65.3 and 58.1 with the cognitive TUG test for predicting the occurrence of falls. While Cardon-Verbecq et al ( 2017 ) also did not find an improved predictive ability in a study with 157 participants, and Sailer ( 2016 ) did not find the cognitive TUG to be an effective measure of fall risk in 14 participants. Shumway-Cook et al ( 2000 ) reported in a study with 30 participants that TUG's ability to predict falls is not enhanced by adding a secondary task. Authors such as Hofheinz and Mibs ( 2016 ) reported AUC curve results of a study with 120 patients for TUG with manual task 0.65 and for standard TUG 0.58, respectively. Looking at gait characteristics, Greene et al ( 2010 ) used body-worn sensors while each patient performed the TUG test. This method offered an improvement by using gait characteristics to discriminate between fallers and non-fallers. In particular, gait variability may seem to confer the risk of falling (Callisaya et al 2011 , Hausdorff et al 2001 ). Van Schooten et al reported daily-life assessments and gait quality as useful predictors for falls with an AUC up to 0.76 (Van Schooten et al 2016 ).

Besides body-worn sensors, clinical trials using motion analysis systems with cameras and reflective markers placed on specific anatomic points to assess the time of TUG subtasks for fallers and non-fallers also have shown significant differences (Ansai et al 2018 , Li et al 2018 ). Other automatic TUG test analysis technologies exist like Higashi et al 's ( 2008 ), who investigated the detection of TUG subtasks by using gyroscopes and accelerometers attached to the subjects' waists and lower limbs. Salarin et al ( 2010 ) published an instrumented version of TUG, called iTUG, or there is a solution called aTUG provided by Frenken et al ( 2011 ) which is based on the usage of ambient sensor technologies like light barriers, force sensors, and a laser range scanner built into a single apparatus in a chair.

As an alternative to the complex video-based systems and body-worn sensors, we developed a method to evaluate the TUG test, different TUG subtasks and additional gait characteristics with an ultrasonic sensor (Ziegl et al 2018 ). This method provides a distance over time curve with features not used for fall prediction so far.

The present study compared the fall risk derived from state-of-the-art risk scores with the TUG time and specific parameters from the TUG distance over time curve.

2.1. Study design

The study was conducted between February and July 2018. During the 15 weeks of study, TUG measurements were recorded six times (one TUG measurement every three weeks). Demographic data were collected at baseline. Medication intake was recorded for each participant at baseline and at the date of the last TUG measurement. All falls of the participants were recorded with the exact date and time during the period from November 2017 to December 2018 (figure 1 ). The detailed timeline for each participant within the measurement period can be seen in figure 2 .

Figure 1.

Figure 1.  Fall screening period in months.

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Figure 2.

Figure 2.  Measurement period in weeks with marked observations.

Ethical approval was obtained by the ethics committee of the Medical University of Graz (GZ: ABT08-182942j2016 PN:8011; 30.1.2018).

2.2. Participants

Persons of age ≥ 65 years from four different nursing homes operated by the Geriatric Health Care Center Graz were enrolled in the study. Persons with the following criteria were included:

  • 1.   Age 65 years and older.
  • 2.   Mobile, able to walk the complete TUG distance and back (walking aids like walkers and walking sticks were allowed).
  • 3.   Living in one of the four participating geriatric nursing homes in Graz.
  • 4.   Cognitive competent to give a declaration of consent.

The exclusion criteria included:

  • 1.   Not living in one of the four participating geriatric nursing homes in Graz.
  • 2.   Suffering from a tumor or other severe illnesses.
  • 3.   Being immobile.
  • 4.   Suffering from a severe dementia.

All participants gave written informed and written consent prior to inclusion in the study.

2.3. Frailty assessment, quality of life measurement and medication

For frailty assessment, two questionnaires were used, i.e. the Groningen Frailty Indicator (GFI) (Drubbel et al 2013 ) and a modified version of the Falls Efficacy Scale created by Tinetti et al ( 1990 ). The GFI is a 15-item questionnaire—with a score range from zero to fifteen—that assesses the physical, cognitive, social and psychological abilities of a person. With a GFI score of four or greater, a person can be categorized as frail.

The Falls Efficacy Scale consists of ten activity items that can be rated with a score from 1 (very confident) to 10 (not confident at all). The query 'Prepare meals not requiring carrying heavy or hot objects' was excluded from the list of activities as the participants of this study did not perform this task in their daily life. Consequently, a maximum score between 0 and 90 was possible. A total score of greater than 70 indicates that the person has a fear of falling.

To assess the quality of life, the EQ-VAS (5 l version) questionnaire has been used. This is a scale numbered from 0 to 100: 100 implies the best possible health status and 0 the worst possible health (Feng et al 2014 ).

Prescribed medications of all patients were noted at the begin of the measurement period and at the date of the last TUG measurement. The number of medications was calculated as the total sum of drugs. Furthermore, each medication was classified on the basis whether it contained Benzodiazepines or not, as Benzodiazepines are associated with a greater fall risk (José et al 2017 ).

2.4. Timed up-and-go (TUG) recording

The TUG measurements were done with a previously developed ultrasonic TUG device (Ziegl et al 2017 ). Attached to the backrest of a chair, it measured with a sampling frequency of 10 Hz the distance to the participant. The chair with the device was placed in front of a wall. After switching on the device, it guided the user to adjust the device correctly, 3.5 meters away from a wall. When the participant was correctly sitting on the chair (distance < 10 cm for > 5 samples, i.e. > 0.5 s), the device gave an acoustic start signal. The participant walked to the wall, turned around and walked back to the chair. Upon sitting down (distance < 10 cm), the device stopped the recordings and evaluated the test (Ziegl et al 2017 ). The sampled distance values for every test were directly stored on the device and later transmitted to a PC.

2.5. Statistical analysis

Statistical analysis was carried out using our Predictive Analytics Toolset for Health and Care Applications (PATH) (Hayn et al 2018 ), a MATLAB ® based system. In addition to statistics, PATH was used for data management, signal processing, and Machine Learning functionalities (Sams et al 2019 ).

We attempted to classify fallers and non-fallers using demographic data, frailty evaluations and TUG recordings with all their sub-features. Participants were classified as fallers if they had been falling at least once within the fall screening period which includes some months before and after the measurement period. If more than one TUG test was performed by a single patient, the mean value of each feature as achieved from the consecutive tests was used for further analyses. To compare the results of fallers and non-fallers, we used two-sided unpaired u-tests. P < 0.05 was considered to indicate statistical significance. Descriptive statistics are presented as mean ± SD and as boxplots, which show the distribution of the measured parameter for fallers and non-fallers. Furthermore, the median (MED), the interquartile range (IQR) and the minimum (MIN) and maximum (MAX) values are displayed in the figures.

To evaluate the performance of different classifiers, we calculated the 'True Positive Rate' (TP) and 'False Positive Rate' (FP) for different thresholds. TP was plotted against FP results in the Receiver Operating Characteristic (ROC) curve. The 'AUC' was used as measure of the classification performance (also known as C-statistics).

2.6. Signal processing and feature extraction

Figure 3 shows the signal processing and the first part of feature extraction from the 'Raw TUG data'. Spikes were detected as super-threshold absolute values of gradients greater than 4 m s −1 , resulting in a curve named 'TUG data after spike removal'. Absolute distances were used to mark segments corresponding to subtask like sitting up, walking forward, turning around, walking back and sitting down, as detailed in Ziegl et al ( 2018 ).

Figure 3.

Figure 3.  Example for feature extraction from a TUG distance over time curve based on normal distribution fitting after spike removal.

2.7. Normal distribution fitting

As can be seen in figure 3 , a Gaussian bell-shaped curve (probability density function of a normally distributed random variable) ('Fitted curve') was fitted into a marked area ('Selected fitting data'). This area consisted of two parts (left and right) that reached from the sit-to-stand point to 50 cm before the turn as well from 50 cm after the turn to the begin of the sitting down period. The fitting was done by using both segments of 'selected fitting data' of the curve. The coefficients of the following model were estimated:

with a , b , c , and d being the coefficients of the normal distribution approximation. The proportion of the total sum of squares explained by the model as a scalar was calculated as following:

SSE was the sum of squared error, SSR the sum of squares accounted for by the regression and TSS the total sum of squares of the dependent variable.

Alternative start ('Alt. start') and alternative stop ('Alt. stop') points were calculated by determining the intersections of tangents at the highest gradients of the fitted curve with the horizontal line at y = 0.

2.8. Linear fitting

Figure 4.

Figure 4.  Example of feature extraction from a TUG distance over time curve based on linear regression after spike removal.

The walking time was calculated by subtracting the point 'Alt.stop' with the point of 'Alt. start'.

The list of features extracted based on the fitting includes:

  • RMSE (Root Mean Squared Error)
  • R 2 (Proportion of the total sum of squares explained by the model as a scalar)
  • k (Mean of β 1 and β 3 for left and right side of the Linear Regression model)
  • Gradient difference (Difference of β 1 [left] and β 3 [right])
  • v_max (Speed of the left half)
  • v_min (Speed of the right half)
  • Alt. start (Alternative starting point)
  • Alt. stop (Alternative endpoint)
  • Walking time (Difference between 'Alt. start' and 'Alt. stop' point)

We recruited 46 residents from four nursing homes in Graz. Seven of them were excluded due to a health status preventing them from performing the measurements or because they declined to participate in the study, resulting in a remaining number of 39 participants. During the measurement period, 23 participants fell at least once and in total 75 times (in average 3.3 ± 5.1 times).

3.1. Timed up-and-go (TUG) features as fall classifiers

From all parameters, TUG signal features showed the best performance when applied as fall classifiers. The R 2 coefficient exhibited significant differences between fallers and non-fallers with p < 0.05 for normal distribution fitting and p < 0.02 for linear regression fitting. Both distributions of values for R 2 can been seen in figure 5 . The complete TUG time values tended to be longer in fallers but did not reach significance ( p = 0.19). Similar results were achieved for the total sit-to-stand time ( p = 0.07). Both distributions are shown in figure 6 . The R 2 parameters for normal distribution and linear regression fitting were selected due to their significance. All four parameters are evaluated as classifiers with a receiver operating characteristic in figure 7 .

Figure 5.

Figure 5.   R 2 proportion of the normal distribution fitting and linear regression model.

Figure 6.

Figure 6.  TUG time and the subtask feature sit-up time used to differentiate between fallers and non-fallers.

Figure 7.

Figure 7.  Receiver operating characteristic for R 2 Linear Regression, R 2 Normal Distribution, Sit-up time and TUG time.

3.2. Assessment of the fitting

To evaluate the fitting process for the Normal distribution and linear fitting the calculated upper adjacent, median and lower adjacent for the distribution of R 2 Normal Distribution (left) and R 2 Linear Regression (right) were calculated. These values are shown in table 1 . The distribution of these values is shown in figure 8 as boxplots. Figure 9 shows example signals for signals from different participants with these parameters.

Figure 8.

Figure 8.  Distribution of R 2 Normal Distribution (left) and R 2 Linear Regression (right).

Figure 9.

Figure 9.  Example signals for the Upper Adjacent (top), Median (middle) and Lower Adjacent (bottom) of R 2 Normal Distribution (left) and Linear Regression (right).

Table 1.  Upper adjacent, median and lower adjacent values for R 2 Normal Distribution and R 2 Linear Regression.

  Normal Distribution Linear Regression
Upper adjacent0.99930.9995
Median0.99250.9949
Lower adjacent0.97070.9833

All features evaluated for fall classification can be seen in table 2 .

Table 2.  Descriptive statistics (mean ± standard deviation) and p -values for the difference (two tailed U-test) between the groups of fallers and Non-fallers.

Name of featureNon-fallersFallers Value of both groupsNon-fallers versus fallers -value
    
Age, years85.2 ± 8.083.6 ± 8.484.2 ± 8.20.81
Weight, kg61.5 ± 13.270.3 ± 14.266.7 ± 14.30.16
Height, cm156.1 ± 8.3162.7 ± 9.2160.0 ± 9.3< 0.05
BMI25.4 ± 6.026.5 ± 4.526.0 ± 5.10.81
Gender (Female, %), n16 (100%)20 (87%)36 (92.3%)0.16
    
Medication count, n7.1 ± 2.76.2 ± 3.06.5 ± 2.90.73
Benzodiazephine, n3 (18.8%)2 (8.7%)5 (12.8%)1.00
    
EQ5D-VAS mean56.2 ± 21.759.7 ± 14.858.2 ± 17.80.52
Groningen Frailty Index Baseline2.1 ± 1.52.3 ± 1.92.2 ± 1.70.54
Groningen Frailty Index Endtest2.4 ± 0.82.6 ± 1.22.5 ± 1.00.85
Falls Efficacy Scale Baseline32.8 ± 14.237.4 ± 18.535.4 ± 16.70.57
Falls Efficacy Scale Endtest36.3 ± 12.739.9 ± 13.838.11 ± 13.10.47
    
TUG time, s19.9 ± 6.927.2 ± 17.524.2 ± 14.50.19
Walkback time, s4.5 ± 2.56.1 ± 5.25.4 ± 4.30.31
Walking time, s8.2 ± 3.610.7 ± 7.39.6 ± 6.10.24
Mobilitymanouvre time, s11.7 ± 3.615.7 ± 10.414.0 ± 8.40.21
Sit-down time, s4.7 ± 2.26.3 ± 5.55.6 ± 4.40.56
Sit-up time, s4.1 ± 1.66.3 ± 4.45.4 ± 3.70.07
Turnaround time, s2.8 ± 1.23.3 ± 1.13.1 ± 1.20.18
Walkforward time, s3.7 ± 1.24.6 ± 2.34.2 ± 1.90.21
    
RMSE4.4 ± 0.84.9 ± 1.04.7 ± 0.90.07
Alt. start2.9 ± 1.94.2 ± 2.83.7 ± 2.50.08
Alt. stop16.3 ± 5.021.1 ± 10.819.1 ± 9.10.16
Walking time13.4 ± 3.516.8 ± 8.215.4 ± 6.90.17
0.990 ± 0.0050.986 ± 0.0050.988 ± 0.005
v_max5.8 ± 2.77.9 ± 4.57.0 ± 3.90.11
v_min13.3 ± 4.317.3 ± 9.315.7 ± 7.90.12
    
RMSE3.4 ± 0.63.7 ± 0.73.6 ± 0.70.28
Walking time14.0 ± 4.317.7 ± 8.916.2 ± 7.50.15
0.994 ± 0.0030.991 ± 0.0050.992 ± 0.004
k67.6 ± 19.658.6 ± 22.262.3 ± 21.40.24
Gradient difference4.7 ± 6.01.9 ± 5.73.1 ± 5.90.20

4. Discussion

With this study we have tried to get new insights in the functional health state and consequently the risk of falling of elderly people. We compared various parameters as derived from the TUG test, medication and state-of-the-art frailty assessment scales with respect to their link to falls. The coefficient of determination for Gaussian bell-shaped curves and linear regression lines significantly separated fallers from non-fallers. Subtasks of the Timed Up-and-Go test like the sit-up time showed near significance. Neither the amount of medication nor a binary value (Benzodiazepine yes/no) varied between fallers and non-fallers. The same was the case for the modified version of the Falls Efficacy Scale by Tinetti and the GFI.

Calculating the subtask features from the signal which is based on total distances led to a better separation of fallers and non-fallers. A p -value close to significance (0.07) was found for the sit-up time. When analyzing the TUG curves, we visually identified that non-fallers seemed to have more regular and smooth TUG curves as compared to fallers. These findings can be interpreted as gait variability which is derived from fluctuations in gait rhythm of the participant and associated with the risk of falling in elderly people. We tried to quantify this variability by fitting a normal distribution into the distance over time TUG curve. R 2 , the mean squared error between the fitted curve and the actual values. The significantly different values for this parameter obtained from fallers and non-fallers indicates that this parameter may indeed help to separate fallers and non-fallers. It was noticeable, that the shape of the rising and falling flank was often smooth but had different gradients. Therefore, linear regression for each flank was determined separately. The R 2 parameter for this type of modelling also led to a significant difference between fallers and non-fallers.

Our literature research showed different results for calculating the ability of TUG to predict falls. The AUCs reached from 0.58 to 0.76. The higher areas were mostly achieved by considering additional tasks and parameters than just the TUG time. Therefore, our resulting AUC for R 2 of the Linear Regression model of 0.74 as well as R 2 of Normal Distribution model of 0.71 can be considered as strong markers compared to the state-of-the-art. These results could potentially be translated into practice by identifying people who have a high risk of falling and offering them mobility programs to counteract muscle weakness, balance and gait problems to prevent them from falling. Due to the simplicity and non-invasiveness of the TUG measurement method, repeated use for the assessment of medium and long-term intraindividual changes is possible. However, the potential benefit for trend monitoring should be evaluated in a follow-up study. Originally, we planned to recruit 60 persons and expected a dropout rate of 20%. Finally, 46 of them signed an informed consent and 39 of them attended at least one measurement session. This resulted in a lower dropout rate of 15%(expected dropout 20%) but also a lower number of participants in total and a correspondingly lower statistical power to detect significant differences between fallers and non-fallers. Also, the numbers of male and female participants were unbalanced. With a median TUG time of 24.2 s, most of the participants in our study exhibited values well beyond 13.5 s, the widely used cut-off time to identify individuals at higher risk of falling used in the existing literature. This generally low level of mobility in our cohort needs to be taken into account when transferring our findings to more vigorous cohorts with shorter TUG times.

Nevertheless, we found significant differences between fallers and non-fallers in features obtained from fitting normal distribution and linear regression models to the TUG distance over time curve. Neither information from medication data or quality of life or frailty questionnaires was significantly related with falling, nor the complete TUG time, although the latter came close to significance.

As the TUG distance values resulted from an ultrasonic measurement including noise, signal processing was necessary. Observed disturbances were mostly spikes that resulted from specular reflectance and acoustic noise. We managed this issue by looking at high derivative values in the signal and furthermore by detecting the beginning and the end of every spike, before removing it. This processing step worked well in the supervised setting, where all TUG tests were performed correctly. In an unsupervised setting, unusual TUG runs could happen which could bring the spike detection algorithm to its limits, potentially necessitating an adapted algorithm in such a setting.

Fall prediction based on automated TUG recordings could help to prevent falls in persons, who perform the test at home. In conclusion, we have found completely new indicators that seem to be superior to previously investigated once. Even if falls still remain hard to predict, these indicators could potentially open a new route for assessing elderly patient's risk of falling. If confirmed in a larger and potentially better-balanced population, this approach could lead to advances in falls risk prediction in terms of time consumption and precision as compared to existing methods.

Acknowledgments

This work was partly funded by the 'Zukunftsfonds des Landes Steiermark' (GZ: ABT08-182942j2016 PN:8011).

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Article Contents

Fall message, conditions that shifted nurses to progress fall risk patients, limitations, conclusions, acknowledgments.

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Impact of Fall Prevention on Nurses and Care of Fall Risk Patients

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Barbara King, Kristen Pecanac, Anna Krupp, Daniel Liebzeit, Jane Mahoney, Impact of Fall Prevention on Nurses and Care of Fall Risk Patients, The Gerontologist , Volume 58, Issue 2, April 2018, Pages 331–340, https://doi.org/10.1093/geront/gnw156

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Falls are common events for hospitalized older adults, resulting in negative outcomes both for patients and hospitals. The Center for Medicare and Medicaid (CMS) has placed pressure on hospital administrators by identifying falls as a “never event”, resulting in a zero falls goal for many hospitals. Staff nurses are responsible for providing direct care to patients and for meeting the hospital no falls goal. Little is known about the impact of “zero falls” on nurses, patients and the organization.

A qualitative study, using Grounded Dimensional Analysis (GDA) was conducted to explore nurses’ experiences with fall prevention in hospital settings and the impact of those experiences on how nurses provide care to fall risk patients. Twenty-seven registered nurses and certified nursing assistants participated in in-depth interviews. Open, axial and selective coding was used to analyze data. A conceptual model which illustrates the impact of intense messaging from nursing administration to prevent patient falls on nurses, actions nurses take to address the message and the consequences to nurses, older adult patients and to the organization was developed.

Intense messaging from hospital administration to achieve zero falls resulted in nurses developing a fear of falls, protecting self and unit, and restricting fall risk patients as a way to stop messages and meet the hospital goal.

Results of this study identify unintended consequences of fall prevention message on nurses and older adult patients. Further research is needed understand how nurse care for fall risk patients.

Falls in older adults are a major public health concern often resulting in longstanding pain, functional impairment, disability, premature nursing home admission, increased length of stay in hospitals, and mortality ( Inouye, Brown, & Tinetti, 2009 ; Mahoney, 1998 ; Oliver, Hopper, & Seed, 2000 ). Patient falls in hospitals are common with rates varying from 3 to 17.1 falls per 1,000 beds days ( Halfon, Eggli, Van Melle, & Vagnair, 2001 ; Oliver et al., 2000 ). A longitudinal study using National Database of Nursing Quality Indicators (NDNQI) data collected from 2004 to 2009 found a decrease in overall patient fall rates ( He, Dunton, & Staggs, 2012 ). However, falls in hospitals commonly occur in adults older than 65 years ( MacCulloch, Gardner, & Bonner, 2007 ). In hospitalized older adults, falls have steadily increased over the past 3 decades with numbers projected to rise significantly due to substantial increases in the aging population ( Wanless, 2006 ).

The occurrence of patient falls has been identified by Centers for Medicare and Medicaid Services (CMS) as one of eight “never events” for hospital settings. Never events are high-cost, high-volume events that could be reasonably prevented by the application of evidence-based guidelines ( Rosenthal, 2007 ; Waters et al., 2015 ). A recent impact assessment, however, found that the CMS policy has had no effect on the rates of injurious falls, perhaps because there are no evidence-based practice guidelines for fall prevention ( Waters et al., 2015 ), and few intervention studies have been conducted on fall prevention in hospital settings with minimal evidence to inform practice. Of those conducted, results have been mixed. A 2012 Cochrane review ( Cameron et al., 2012 ) found that multifactorial programs are effective for patients who have a longer length of stay, but no recommendations could be made for any component of these programs. Other systematic reviews found that either there was no conclusive evidence that fall prevention programs reduce the number of falls ( Coussement et al., 2008 ) or that multifaceted interventions may have a modest effect on falls, but not on fractures ( Oliver et al., 2007 ).

In hospitals, patient falls have a multifactorial etiology that can be subdivided into three categories: (a) physiological anticipated (gait instability, fall history, and current risk for falls); (b) physiological unanticipated (fainting); and (c) environmental (external hazards or equipment failure) ( Oliver et al., 2000 ). In addition, individual inpatient units have unique characteristics related to type of patients, staffing ratios, model of care, environment, and equipment availability, which also affect patient fall rates ( Oliver et al., 2000 ). Due to the complexity of falls in hospital settings, a one-size-fits-all approach to reducing or preventing patient falls may not be feasible.

Staff nurses may have the greatest impact on reducing patient falls. Due to their 24-hr presence, nurses have the most consistent contact with patients and continually monitor for conditional changes. However, no research has been conducted on how nurses approach fall prevention or the multiple strategies they use to reduce the risk or prevent falls in older adult patients. When falls occur, nurses often become the “second victim” expressing increased stress, anxiety, guilt, concern for liability, and self-doubt about the quality of care they provide ( Brians, Alexander, Grota, Chen, & Dumas, 1991 ). The American Nurses Association (1999) and the National Quality Forum (2004) use patient falls as a nursing-sensitive quality indicator, placing the responsibility for patient falls directly on nursing staff. This blame, along with potential pressure from administration to reduce falls due to CMS penalties may alter how nurses care for fall risk patients.

The purpose of this Grounded Dimensional Analysis (GDA) study was to explore nurses’ experiences with fall prevention in hospital settings and the impact of those experiences on how nurses provide care to fall risk patients. The model developed in this study illustrates the impact on nurses of intense messaging from nursing administration to prevent falls and the consequences to older adult patients, staff nurses, and the organization.

Before conducting the study, Institutional Review Board approval was obtained. The study was initiated on July, 2013 and completed on December, 2014. GDA, a variant of Grounded Theory ( Bowers & Schatzman, 2009 ), was used to explore acute care nurses’ experiences with fall prevention and how those experiences influenced care of older adult fall risk patients. Similar to Grounded Theory, GDA is informed by symbolic interactionism which focuses on exploring how individuals assign meaning based on interactions with others and actions taken based on those interpretations ( Blumer, 1998 ). GDA is particularly well suited to discovery in areas where little is known and the focus is on individuals’ understandings and perceptions. GDA uses a cyclic process for sampling (open and theoretical), data collection, and analysis (open, axial, and selective; Strauss, 2008 ). Unlike Grounded Theory, open coding tends to continue longer during GDA to avoid early narrowing of focus and premature closure. Maintaining open coding is strategically done to explore “what all is involved” ( Schatzman, 1991 ). For this study, open coding was continued through the fifth interview. The end result of a GDA study is the creation of a conceptual model which explains the interaction among the primary components of a social process ( Strauss, 2008 ).

Data were collected from two hospitals located in Wisconsin. The study sites differed in the number of patient days for people older than 65 years and in bed capacity. Site A bed capacity is 530 with a reported percentage of patient bed days for adults older than 65 years of 34.3%. Site B bed capacity is 81 beds with a reported percentage of patient bed days for adults older than 65 years of 54.4%. Both hospitals are designated as teaching hospitals and have a nurse to patient ratio of 1:4.

Several recruitment strategies were used, including announcing the study at unit meetings (staff meetings and unit council meetings), e-mail invitations, and flyers placed in nursing staff mailboxes. In the early phase, recruitment was open to all members of the nursing staff who care for patients identified as fall risk on the participating units. Open sampling techniques were used to uncover as many relevant categories and dimensions as possible ( Strauss, 2008 ). As categories were developed, theoretical sampling was used to ensure density of categories, capture variation in how nursing staff perceived and cared for fall risk patients, and further the development of a conceptual model ( Strauss, 2008 ). For example, staff registered nurses (RNs) who served in formal leadership roles (charge nurse, care team leader, and representative on a falls committee) seemed to perceive fall risk patients differently than nurses in nonleadership roles and described promoting patient mobility as a means of preventing falls, rather than limiting patient mobility. The researcher actively sought out these RNs by asking nurse managers on inpatient units to provide names of individuals who served in a leadership capacity. Further, there was a noticeable difference between RNs and certified nursing assistants (CNAs) in how they described their experiences with patient falls and how fall prevention was implemented on their units. As RNs expressed feeling more responsible and frustrated with increased additional work resulting from patient falls and were more descriptive in how they restricted patient activity compared with CNAs, a methodological decision was made to increase recruitment and sampling of RNs. Recruitment and sampling continued until saturation was reached, and fresh data no longer revealed new theoretical insights or new properties of the categories ( Charmaz, 2014 ).

The sample consisted of 27 RNs and CNAs who were employed on a medical, surgical, or medical/surgical adult inpatient unit and caring for patients aged 65 years and older. Site A sample consisted of 2 nurse managers, 1 clinical nurse specialist (CNS), 2 CNAs, and 11 RNs. Site B sample consisted of 10 RNs and 1 charge nurse (management). This study did not collect participant demographic data. In a Grounded Theory study, deciding who to sample is based on the dimensions that are salient to the categories that emerge from the data ( Strauss, 2008 ).

Data Collection and Analysis

In GDA, data collection and analysis occur iteratively. In-depth, one-on-one interviews ( N = 22 participants) and a focus group ( N = 5 participants) lasting approximately 30–60min were conducted. All interviews were held in a private office and were audio recorded and transcribed verbatim. Unstructured open-ended questions were used initially. For example, all participants were asked, “What is it like for you to take care of an older adult patient who is identified as a fall risk”? Based on the participant responses, additional broad questions were asked to help identify all possible dimensions of participant experiences. Most participants described fall risk patients as burdensome and making them feel nervous when providing care during their work shift. Focused questions were asked once initial categories and dimensions had been labeled. For example, with fear of falls category, focused questions included, “Some nurses have described feeling like they would get into trouble if their patient fell, have you experienced this? Can you describe for me your concerns about getting into trouble”?

Data were analyzed using open, axial, and selective coding ( Strauss, 2008 ). Open coding involved a line-by-line analysis to break down the data into concepts. Similar concepts were grouped into categories. Axial coding involved identifying properties and dimensions of categories answering questions related to when, where, who, how, and with what consequences ( Strauss, 2008 ). Axial coding allowed the researcher to describe nurses’ experience with caring for fall risk patients with great detail and provided linkages between categories. Selective coding was used to systematically relate all categories to each other and to finalize the conceptual model.

Several strategies were used to ensure rigor of the study. Data were analyzed within a group experienced with GDA who were skilled at identifying researcher imposed categories not grounded in the data, making it less likely that preconceived assumptions would be imposed. Memoing was used throughout to inform sampling, data collection, and analysis; record analytic decisions; and provide a record of how decisional matrixes evolved to describe the relationship among categories. Member checking was used during focused interviews. At the end of interviews, participants were shown a decisional matrix which identified categories and asked to provide feedback on missing properties or dimensions and suggest any alternative explanations for interactions among categories. Finally, each category and the relationships among categories were tested by locating supportive quotes from multiple interviews ( Strauss, 2008 ).

All participants stated that the goal within their institution was “zero falls.” Falls were defined by staff nurses as any occurrence in which the patient descends to the floor. Many nurses described frustration in this definition, because even if a patient was intentionally lowered to the floor to prevent injury, the event was counted against them. There was variation within and between institutions in the pressure nurses experienced related to meeting an institution’s goal. Nurses who worked on inpatient adult units with high fall rates described experiencing intense pressure, in the form of frequent messages from nursing administration (senior-level and midlevel), to “get the number down.” The more intense the message, the more they altered their nursing care by restricting patient mobility—an upright, mobile patient is one who can fall. Conversely, nurses who worked on inpatient adult units with low fall rates did not experience similar pressures. These nurses engaged in behaviors to promote and encourage independent patient mobility regardless of whether the patient was identified as fall risk. How nurses respond to fall prevention messages delivered by nursing administration is illustrated in Figure 1 .

Acute care nurse perceptions of fall prevention.

Acute care nurse perceptions of fall prevention.

Participants consistently identified their units as being labeled either a high- or a low-fall unit. Nurses stated that the label of high- or low-fall unit was communicated to them by nursing administration. Being identified as a high-fall unit occurred if the unit had more than 2 falls monthly, whereas low-fall units had occasional falls, every 3–6 months. Intensity of the zero falls message was related to how often the message was sent, who sent the message, and the message tone (positive or negative). The tone delivered to high-fall units was often blame and shame and targeted individual staff involved in patient falls. Such messaging led nurses to develop a fear of falls and a need to protect themselves and the unit from being labeled as a bad unit. For nurses on high-fall units, the best way to achieve the hospital goal and stop the message was to restrict patient mobility.

In contrast, the fall message was experienced differently by nurses who worked on low-fall units. For these nurses, the message was positive because they were meeting the hospital goal. When falls did occur, nurses on low-fall units did not describe feeling blamed or shamed, but rather stated the focus was on identifying problems within the unit (environmental) or the patient (weakness) that may have contributed to the fall. Nurses on low-fall units did not talk about protecting self and unit. Instead of restricting patients, they described promoting patient ambulation with the goal of progressing patients.

Intense Messaging

Patient falls triggered a cascade of messages from a variety of sources, senior nursing administration (chief nursing officer, director of inpatient services, and director of quality and safety), midlevel nursing administration (nurse manager and CNS), and unit level (charge nurse) about why falls continued to occur. Table 1 identifies the source of the message and the frequency of occurrence. On high-fall units, the frequency of messages about falls was intense and occurred on a daily, weekly, and monthly basis, as well as after every fall. The flow of messages occurred between senior-level and midlevel nurse administration, senior nursing administration to staff RNs on the unit, midlevel nursing administration to staff RN, and staff RN to other RNs, and CNAs on the unit. Messages were delivered by several means, in person (shift report, post fall huddle, unit and hospital wide meetings, and post fall investigation); phone (to notify midlevel manager of fall); e-mail (to all hospital units that a fall occurred); and public postings (number of fall free days on each unit). Because of the intense fall reduction message, RNs on high-fall units stated they often over identify fall risk patients leading to an overwhelming list of patients for whom nurses felt they must take extra precautions to ensure falls did not occur on their shift.

Source of Messaging

MessagingLow-fall unitHigh-fall unit
Routine
 At the beginning of each shift, the charge nurse announces to all nursing staff which patients are at risk for fallingX
 Daily e-mail from senior administration to all nursing staff and administration about falls that have occurredX
 Daily posting of number of “Fall free days” in a common space that is visible to everyone, including patientsX
 Weekly e-mail from senior administration to all nursing staff and midlevel administration about falls that have occurredX
 Monthly discussion of patient falls during unit council meetings between midlevel administration and nursing staff representativesXX
 Monthly discussion of patient falls during unit level meetings between midlevel administration and nursing staffX
 Monthly discussion of patient falls during nursing leadership meetings between midlevel administration and senior administrationXX
Triggered by fall
 Post fall huddleX
 Nurse documents fall in an error reporting system that is sent to midlevel administration and senior administrationXX
 Nurse calls midlevel administrator post fall, anytime day/nightX
 E-mail from senior administration to midlevel administration about fall eventX
 Investigation about the fall event by midlevel administrationX
MessagingLow-fall unitHigh-fall unit
Routine
 At the beginning of each shift, the charge nurse announces to all nursing staff which patients are at risk for fallingX
 Daily e-mail from senior administration to all nursing staff and administration about falls that have occurredX
 Daily posting of number of “Fall free days” in a common space that is visible to everyone, including patientsX
 Weekly e-mail from senior administration to all nursing staff and midlevel administration about falls that have occurredX
 Monthly discussion of patient falls during unit council meetings between midlevel administration and nursing staff representativesXX
 Monthly discussion of patient falls during unit level meetings between midlevel administration and nursing staffX
 Monthly discussion of patient falls during nursing leadership meetings between midlevel administration and senior administrationXX
Triggered by fall
 Post fall huddleX
 Nurse documents fall in an error reporting system that is sent to midlevel administration and senior administrationXX
 Nurse calls midlevel administrator post fall, anytime day/nightX
 E-mail from senior administration to midlevel administration about fall eventX
 Investigation about the fall event by midlevel administrationX
“On a unit like mine, we have a lot of people that are always identified as fall risk. I think out of 28 people we have 25 high fall risk” (Interview 6).

Daily messages also occurred as posting of fall free days. The unit’s progress of how many days without having a patient fall is displayed to everyone on the unit (nursing staff, other health care providers, patients, and family members), because it is posted in a prominent location next to the nurses station. Even when the unit made good progress by going multiple days without a fall, many nurses described a sense of heightened anxiety around not wanting to be the one who ended the “streak.” When a fall occurred, seeing a zero posted was interpreted by nurses as failure and having to start all over again.

“That zero is really awful to see, you have to start all over again, you don’t want to see a zero” (Interview 5).

Weekly and monthly messages were delivered in meetings, such as monthly unit staff meetings, monthly unit council meetings (attended by a staff RN representative from various inpatient units), and weekly nursing leadership meetings (between midlevel and senior nursing administration), or in the monthly hospital falls report e-mailed to all staff nurses and nurse administrators employed in the organization. These messages compared unit to unit success or failure in meeting the hospital goal, announced when and where falls had occurred, and served as an additional source of pressure on high-fall units. Staff RNs from high-fall units who participated in monthly meetings often described feeling frustrated that their unit was identified as a “bad” unit.

“When I go to unit council, I can see the scores and see that my unit is one of the higher units…other people look at it and compare themselves…‘oh look at this unit’. It makes us feel bad” (Interview 10).

Monthly meetings that included only senior-level and midlevel nursing administration often led to midlevel managers feeling blamed that their units were not meeting the goal and could jeopardize the hospital Magnet status designation.

“And we met, there was a lot of push ‘falls aren’t okay’ and we met for about an hour and a half and it was pretty negative. I remember it being painful” (Interview 1).

Staff RNs also have to notify senior-level and midlevel nursing administration every time a fall occurs. Staff RN notifications occur in the form of a patient safety net (PSN) report and an additional two-page explanation of the fall event. Further, staff nurses on high-fall units must call the unit manager (at any time of the day or week) to report that their patient fell and participate in a personal investigation to determine what the nurse could have done differently to prevent the fall. This process of having to announce a fall made nurses feel they were being scrutinized.

“They look at every aspect. They’re looking at your charting. They’re looking were they on the fall risk, did they have that wristband on and were you on top of it? I think people just feel like they’re under the microscope, which they are” (Interview 9).

After every fall, the messaging intensified because the nurse and the unit are perceived by administration as not doing enough to prevent patient falls. Nurses described increasing intensity of the message as receiving more e-mails from midlevel and senior-level nurse administrators about patient falls, and increasing discussion about patient falls during shift report and unit staff meetings. Nurses on high-fall units stated that falls were always perceived as negative, regardless of the circumstances, even when they were able to safely lower a patient to the ground to avoid injury.

“Somebody had a non-epileptic seizure…I lowered her to the ground…so that was a fall and ruined our score card…all I saw was a ceramic bathroom and a seizing patient…it should be like ‘good job’ but instead it was negative, negative, negative” (Interview 21).

Impact of Fall Message on Nursing Practice

Due to the continual flow and intensity of messages related to patient falls, many nurses on high-fall units identified that they had developed a “fear of falls.” Nurses described fear of falls as concern for and the resulting reprimand if a fall occurred; job security for themselves, unit manager, or CNS; and public exposure of their error to other nurses and hospital administration. Concern for reprimand seemed to be related to the investigation that followed after a patient fell. Nurses had to account in detail all that transpired before, during, and after the fall. This included details about the patient, whether precautions (identifying patient as at risk for falls and placing a bed/chair alarm on the patient) were in place, what happened immediately before the fall and during the fall, and what would have prevented the fall. Nurses often internalized the investigation as personal and felt blamed for the fall event, frightened that they would get into trouble, and defeated.

“She was tearing up, ‘I promise I set the bed exit alarm, I promise, I promise’. Everyone is so afraid of getting into trouble” (Interview 3).

The overwhelming nature of fall investigations and the intensity of messages to reduce falls left nurses concerned that they would lose their job or their unit manager or CNS would be fired if falls continued to occur. The concern for job security was a common statement expressed by nurses, even though they could not identify anyone who had been fired due to patient falls.

“I’m going to get fired…my unit’s going to be the one on the bad list. Somebody from administration is going to come down and we are going to get reamed out. All of a sudden somebody is going to be gone” (Interview 1).

Public exposure occurred when nurses had to announce to the unit nursing staff, to other health care providers (physicians and case managers) or to senior nursing administration that their patient fell. Public announcement occurred during post fall huddle, interdisciplinary rounds, and through e-mails sent to senior nursing administration. Announcements in the form of e-mails were also made to the entire hospital. A post fall huddle involved gathering all nursing staff members who were working during the shift, identify that a patient fell, discuss the causes of the fall, and how the fall event could have been prevented. The post fall huddle was initiated by the nurse who was caring for the patient who fell. Other times nurses had to announce during interdisciplinary rounds that their patient fell. As with fall huddles, nurses had to recount to interdisciplinary health care providers all that transpired before, during, and after the fall.

“A nurse told me that she had to stand up in front of the health care team, physicians, nurses, medical students, and case manager, and tell them that her patient fell. It was awful, she was traumatized” (Interview 18). “If we had a fall it went hospital wide… it was embarrassing. A lot of people felt that was shaming us or blaming us” (Interview 21).

Ultimately, fear of falls resulted in nurses being fearful to care for fall risk patients. Fall risk patients were seen as a threat to nurses in terms of increased workload, blame, and continued flow of negative messages. Fear of falls resulted in nurses altering their practice to protect themselves and the unit.

Nurses primarily protected themselves from the increase in workload that occurred when the nurse had to notify multiple persons in administration that a fall happened, complete several pages of the incident report, call a post fall huddle to discuss the event, and begin the fall investigation. The increase in time demands to notify, document, and investigate, interrupted the nurses’ workflow, putting them even further behind in care duties for all of his/her patients.

“It increases workload when you have a fall and you have to do all those things, the PSN, the phone, and the huddle” (Interview 13). “You’re already feeling bad that your patient fell. So you’re going to get behind now with your work that already was out of control” (Interview 8).

Nurses protected the unit from being identified as a “bad” unit by trying to keep the fall number down. One predominant strategy used by nurses to protect the unit was to pressure all staff to urgently respond when a bed/chair alarm sounded. Nurses rationalized that if someone got to the patient “in time,” a fall would be prevented and their unit numbers would continue to look good to administration. The urgency to respond to alarms led to staff stopping whatever they were doing and running to the source of the alarm. This often resulted in chaos on the unit with multiple staff members running down the hallway at the same time. The need to run to alarms was reinforced among nursing staff and came as a directive from nurse managers. The urgency to respond to alarms put even greater stress on nursing staff and increased their anxiety about caring for fall risk patients.

“Literally the CNS and nurse manager, they look at you and say, ‘I expect you to run into that room, I expect you to move faster’” (Interview 2). “You’re just running down the hallways… We’re all scattered all over the place trying to run to these alarms” (Interview 10).

Restricting

To meet the hospital zero falls goal, nurses on high-fall units often altered how they provided care to fall risk patients by restricting patient movement (containing patients or not allowing ambulation) and privacy. The most efficient way to prevent falls was to not allow fall risk patients to ambulate during their hospital stay. Most nurses described intentionally restricting patient ambulation as a primary strategy for fall prevention, even though they acknowledged that by doing so they could produce poor outcomes for patients in terms of loss of strength. For these nurses, the need to stop intense messaging from nursing administration and meet the hospital goal of zero falls superseded patient needs.

“People are really scared, we can’t have anybody fall, we don’t walk our patients… and then when we do get them up they are weaker and we just shot ourselves in the foot” (Interview 21).

Nurses also restricted fall risk patient movement by containing them. Containing patients was used as a strategy when nurses wanted to get fall risk patients out of bed, but were unable to provide constant surveillance as directed by nurse managers. Containing patients was done by placing them in chairs they could not get out of or by placing patients in chairs next to the nursing station where someone could continually tell them to not get up.

“When I want to get the patient up we use the naughty chair, when you put them in it they can’t get out” (Interview 8).

Restricting patient privacy in the bathroom was also used as a strategy to prevent falls. The decision to restrict patient privacy came as a directive from nursing administration and was based on number of falls that occurred in the patient bathrooms. Nurses stated that patients often objected to their presence in bathrooms and asked the nurse to leave. To get the patient to acquiesce, nurses’ pointed out signs posted in bathrooms that indicated a nurse’s presence was necessary for patient safety or appealed to the patient that a fall would increase their work or that the nurse would get into trouble.

“Sometimes I joke around…if you fall there’ll be a lot of paperwork for me” (Interview 10).

Progressing

In contrast, nurses on low-fall units focused on progressing rather than restricting patients. Progressing patients was described by nurses who worked on low-fall units and by some nurses on high-fall units who focused on the patient and not the fall numbers. Nurses who engaged in progressing patients did not describe fear of falls, need to protect self or unit, or restricting patients. Rather, these nurses focused on patient progression in terms of functional ability and viewed ambulation as a means to maintain the patient’s independence and discharge to home. Nurses progressed patients by maintaining physical strength and promoting safe mobility. Maintaining strength was achieved by getting patients up and out of bed at least to a chair and walking early and often. Maintaining strength was seen as a necessity for independence upon discharge and as a strategy to decrease risk for falls.

“If you’re somebody who needs six walks, I don’t care if you’re a fall risk, we need to get in six walks to get in your exercise” (Interview 15). “The sooner they start, the more they’ll maintain their strength” (Interview 14).

Promoting safe mobility was a strategy to ensure patients walked and was achieved by using ambulation equipment (gait belt and walking device), gathering additional help (another RN or CNA), getting rid of tethers (intravenous lines and drains) that inhibited movement, or having someone walk behind the patient with a wheelchair. Fall risk was not seen as a barrier to ambulation, but rather an indication that additional support during ambulation may be needed.

“We need to get them up, the sooner they walk the better… making sure we have two people walking with them, using a gait belt and a walker” (Interview 14).

Consequences to Nurses and Organization

Consequences to the nurse.

Nurses on high-fall units described feeling overwhelmed by constant messages from nursing administration to prevent falls and the need to be on high alert to ensure that a fall did not occur. This sense of feeling overwhelmed took a physical and emotional toll on nurses. Nurses often described a sense of dread when they started their shift, felt defeated in their efforts, and described low job satisfaction.

“I get very tired physically and mentally because it’s like a roller coaster ride, you know, what’s happening next” (Interview 7).

All nurses stated that a fall prevention protocol that targeted risk reduction for falls was not available on their units. Rather, the three primary mechanisms communicated to nursing staff to reduce falls was to identify patients at risk, place bed/chair alarms on patients, and run to alarms. Because nurses were not reducing risks for falls, their efforts to meet the hospital goal (zero falls) were often not successful, leaving nurses feeling defeated. In addition, as nurses had few successes they often described poor job satisfaction. Several nurses indicated that they were actively looking to transfer to a unit that had low falls.

“It doesn’t feel good when you don’t get the award… it does chip at people. You know, well why don’t I go here and here. I’m going to try IMC nursing” (Interview 6).

Consequences to the Unit

The over identification of fall risk patients in tandem with the “everybody runs” strategy to prevent falls, and the continued messaging that the unit was not meeting the hospital goal, produced low morale on high-fall units. The “everybody runs” culture to prevent falls produced tension between RNs and CNAs. Nurses described scolding nursing assistants or float staff if they did not move fast enough or were not responding to bed/chair alarms. Criticism among nursing staff contributed to low morale.

“You’re afraid of a fall happening so they you’re really hard on your NAs too because you’re like everybody’s got to run” (Interview 10).

In addition, nurses described frustration in not being able to do the right thing for the patient (getting them up to walk) for fear that a fall would occur. Nurses believed if they did allow a fall risk patient to walk about independently they would be breaking a rule. Having their nursing judgment questioned further contributed to low morale on the unit.

“It doesn’t make sense to me, we’re saying just while you’re in the hospital it’s not okay to walk around, but we feel safe enough to have you home by yourself? It makes you a little angry at the person that’s telling you these are the rules. It’s a morale thing, it doesn’t matter what I do, what my decision is, it’s going to be wrong” (Interview 13).

Two conditions were identified that influenced nurse decisions to progress patients identified as fall risk. One condition involved an external source, support from nursing administration, whereas the other was an internal source, nurse characteristics. On several inpatient units, patient ambulation was identified as a priority and encouraged and rewarded by the nurse manager, even if the unit had high fall rates. On these units, ambulating patients was the standard of care used to improve patient outcomes. Nurses were acknowledged for their efforts to get patients up to walk by receiving individual recognition from unit leadership (nurse managers, CNS, and charge nurses). When nurses on high-fall units felt supported by administration they were more likely to ambulate fall risk patients. If a fall did occur on these units, the focus of the investigation was not on individual nurse, but rather included environmental and patient factors (weakness, low blood pressure, and dizziness). Further, the fall investigation was used as a learning experience to improve how the unit could have prevented the fall.

“I don’t feel the high impact from my manager, he’s always encouraging, keep ambulating and doing what you are doing” (Interview 17).

There were also nurse characteristics that prevented nurses who worked on high-fall units from developing a fear of falls. Nurse characteristics that seemed to have a protective effect were being confident in clinical decision making, having a formal (care team leader or charge nurse) or informal (seen as an expert on the unit) leadership role on the unit, and years of experience as a nurse. These nurses were not afraid of ambulating a fall risk patient because they corrected the underlying cause that put the patient at risk for falls (volume depletion, reducing tethers, and discontinuing medications). In addition, they felt secure in their position because they believed they were viewed as a valuable member of the inpatient unit. For these nurses, the focus was on the patient and not the fall number.

“If they’re orthostatic, they might need a couple liters of fluid before I’m going to get them up. After that we get up to walk” (Interview 2).

Responsibility to prevent falls has been placed directly on nursing staff in many hospital settings. Nurses feel increasing pressure to meet the hospital goal of “zero falls” and often feel blamed and shamed when falls occur. Findings from this study provide compelling evidence that nurses experience negative consequences when intense pressure is placed on them to prevent falls. Consequently, many nurses adjust the care they deliver by restricting patient mobility, a strategy inconsistent with optimal patient progress.

In hospitalized older adults, falls are the result of interactions among complex factors including frailty, multiple comorbid conditions, acute illness, unfamiliar environment, and medical/surgical procedures ( Kannus, Seivenan, Palvanen, Jarvinen, & Parkkarri, 2005 ; Lord, Sherrington, Menz, & Close, 2007 ) and are sometimes inevitable ( Oliver et al., 2000 ). Pressuring nurses to meet a zero falls goal may have the unintended consequence of worsening functional status for older patients ( Oliver, 2004 ). Zero falls rates should be viewed with caution; a hospital unit with no falls, is a unit where patients do not move ( Oliver et al., 2000 ).

Nurses’ interviewed acknowledged negative consequences of restricting patient ambulation. However, the need to protect themselves and their unit overrode those concerns. Restricting ambulation and/or enforced bed rest has long been recognized as contributing to muscle mass loss, postural hypotension, and a decrease in maximal work capacity ( Creditor, 1993 ; Kortebein, Ferrando, Lombeida, & Wolfe, 2007 ), all factors that increase an older person’s fall risk ( Mahoney, 1998 ). Many nurses engaged in behaviors that may actually increase fall rates both in hospital settings and when the patient goes home and to the next point of care.

Nurses described three primary strategies used to prevent falls: (a) identify patients at risk; (b) place bed/chair alarms on patients; and (c) run to alarms. However, these strategies have been shown to be ineffective at preventing or reducing falls. Identifying a patient as fall risk does not provide an intervention to target the underlying risk factor ( Oliver, 2007 ; Oliver, McMurdo, Daly, & Martin, 2004 ). In addition, many fall risk identification tools are “home-grown,” and never tested for validity and reliability ( Oliver, 2007 ). The ability to identify fallers and nonfallers can be seriously jeopardized depending on the fall risk identification tool used. Identifying patients at risk may provide nurses with false reassurance.

Nurses also described dependency on bed/chair alarms to alert them when fall risk patients were moving and were pressured by nursing administration to get to the patient when the alarm sounded to prevent the fall. Mass response created chaos on the unit and friction between RNs and CNAs. Further, needing to respond to multiple alarms interrupted nurses’ workflow and increased work demands for all unit staff. In reality, the use of bed/chair alarms produced a negative consequence on nurses and the unit, although this was not overtly recognized by the participants.

The use of bed/chair alarms is controversial. Several studies have demonstrated that these alarms are not effective in reducing fall rate or injurious falls ( Shorr et al., 2012 ; Tideiksaar, Feiner, & Maby, 1993 ). Others have posited that bed/chair alarms are unethical in that they impair a person’s autonomy for free movement, infringe on dignity, and may worsen agitation in confused patients ( Inouye, Brown, & Tinetti, 2009 ; Oliver, 2007 ). Future research should address both the impact of bed/chair alarms on nursing workflow and how older adult patients experience being “alarmed.”

Although patients were not interviewed for this study, one has to wonder how older adults experience and perceive messages from nurses that they are at risk for falls and the impact of restricted ambulation on the development of patient fear of falls. Fear of falls in older adults is associated with self-efficacy. Self-efficacy is influenced by receiving information about the ability to perform an activity (ambulation) from a credible and trustworthy source (nurses) and the actual performance of the activity ( Bandura, 1982 ). Boltz, Resnick, Capezuti, and Shuluk (2014) demonstrated that fear of falls in hospitalized older adults was associated with change in physical function between admission to discharge. Limited ambulation during hospitalization has been identified as an independent predictor of loss of physical function in hospitalized older adults ( Brown, Friedkin, & Inouye, 2004 ; Brown, Redden, Flood, & Allman, 2009 ). Therefore, being told throughout their hospital stay by nurses that they are at risk for falls had having ambulation restricted may be contributing factors to development of fear of falls in hospitalized older adults. Additional research on how hospital fall prevention programs affect older adults needs to be conducted.

Lastly, although falls have been identified as a nursing-sensitive quality indicator of patient care ( National Quality Forum, 2004 ), there has been no empirical evidence on how nurses understood fall prevention and what actions they took to prevent patient falls. Prior intervention studies conducted on fall prevention in hospitals have shown little impact on reducing fall and injuries ( Coussement et al., 2008 ; Oliver et al., 2000 ) due to the complex nature of patient falls in hospitals. A patient centered or unit centered approach to fall prevention has been suggested ( Oliver, 2007 ). But if falls are classified as a “nursing problem” integrating a nursing approach to fall prevention seems key. Additional research is needed to understand how nurses provide care to fall risk patients.

This study had several limitations: (a) Including observations beyond interviews could have strengthened the analysis by allowing the researcher to seek clarification if participants engaged in actions that were not consistent with what they described. (b) As participants were recruited from general inpatient adult medical and surgical units from two hospitals in Wisconsin the results might only be applied to these types of settings. Other hospital units, such as rehabilitation, may produce different results because falls may be seen as an inevitable part of the rehabilitation program and its goal to regaining functional independence for patients.

Falls in older adult patients are a common occurrence in hospital settings. Because of high rates and associated injuries, CMS has identified falls as a “never event” ( CMS Medicare Program, 2007 ). Hospitals have responded by setting zero falls goals and placing pressure on nursing staff to attain the goal. This has resulted in unintended and potentially harmful consequences to nurses and older adult patients. A strong evidence base for care delivery for fall risk patients is lacking. Additional research is needed to gain a better understanding of how nurses (key health care providers in hospital settings) provide care to fall risk patients. There is a need for patient centered and unit-based interventions that prevent patient falls and also preserve patient function.

This work was supported by the Clinical and Translational Science Award (CTSA) program, through the NIH National Center for Advancing Translational Sciences (NCATS), grant UL1TR000427. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

This material is the result of work supported with resources and the use of facilities at the William S. Middleton Memorial Veterans Administration Hospital. The contents do not represent the views of the U.S. Department of Veterans Affairs or the United States Government.

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Impact of Fall Prevention on Nurses and Care of Fall Risk Patients

Affiliations.

  • 1 School of Nursing, University of Wisconsin-Madison.
  • 2 Division of Geriatrics, School of Medicine and Public Health, University of Wisconsin-Madison.
  • PMID: 28011591
  • PMCID: PMC5946811
  • DOI: 10.1093/geront/gnw156

Purpose of the study: Falls are common events for hospitalized older adults, resulting in negative outcomes both for patients and hospitals. The Center for Medicare and Medicaid (CMS) has placed pressure on hospital administrators by identifying falls as a "never event", resulting in a zero falls goal for many hospitals. Staff nurses are responsible for providing direct care to patients and for meeting the hospital no falls goal. Little is known about the impact of "zero falls" on nurses, patients and the organization.

Design and methods: A qualitative study, using Grounded Dimensional Analysis (GDA) was conducted to explore nurses' experiences with fall prevention in hospital settings and the impact of those experiences on how nurses provide care to fall risk patients. Twenty-seven registered nurses and certified nursing assistants participated in in-depth interviews. Open, axial and selective coding was used to analyze data. A conceptual model which illustrates the impact of intense messaging from nursing administration to prevent patient falls on nurses, actions nurses take to address the message and the consequences to nurses, older adult patients and to the organization was developed.

Results: Intense messaging from hospital administration to achieve zero falls resulted in nurses developing a fear of falls, protecting self and unit, and restricting fall risk patients as a way to stop messages and meet the hospital goal.

Implications: Results of this study identify unintended consequences of fall prevention message on nurses and older adult patients. Further research is needed understand how nurse care for fall risk patients.

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Acute care nurse perceptions of fall prevention.

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Open Access

Peer-reviewed

Research Article

Healthcare professional perspectives on barriers and enablers to falls prevention education: A qualitative study

Contributed equally to this work with: Hazel Heng, Debra Kiegaldie, Susan C. Slade, Dana Jazayeri, Louise Shaw, Matthew Knight, Cathy Jones, Anne-Marie Hill, Meg E. Morris

Roles Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Writing – original draft, Writing – review & editing

Affiliation Academic and Research Collaborative in Health, La Trobe University, Bundoora, Victoria, Australia

ORCID logo

Roles Conceptualization, Formal analysis, Funding acquisition, Methodology, Project administration, Resources, Supervision, Writing – review & editing

Affiliations Faculty of Health Science, Youth & Community Studies, Holmesglen Institute, Melbourne, Victoria, Australia, Eastern Health Clinical School, Monash University, Melbourne, Australia

Roles Formal analysis, Investigation, Methodology, Supervision, Writing – review & editing

Roles Conceptualization, Investigation, Supervision, Writing – review & editing

Roles Methodology, Writing – review & editing

Affiliations Academic and Research Collaborative in Health, La Trobe University, Bundoora, Victoria, Australia, Faculty of Health Science, Youth & Community Studies, Holmesglen Institute, Melbourne, Victoria, Australia

Roles Investigation, Resources, Writing – review & editing

Affiliation The Victorian Rehabilitation Centre, Healthscope, Glen Waverley, Victoria, Australia

Roles Resources, Writing – review & editing

Roles Funding acquisition, Supervision, Writing – review & editing

Affiliation School of Allied Health, WA Centre for Health & Ageing, University of Western Australia, Perth, Western Australia, Australia

Roles Conceptualization, Funding acquisition, Methodology, Project administration, Resources, Supervision, Writing – review & editing

* E-mail: [email protected]

Affiliations Academic and Research Collaborative in Health, La Trobe University, Bundoora, Victoria, Australia, Faculty of Health Science, Youth & Community Studies, Holmesglen Institute, Melbourne, Victoria, Australia, Physiotherapy, College of Healthcare Sciences, James Cook University, Townsville, Queensland, Australia

  • Hazel Heng, 
  • Debra Kiegaldie, 
  • Susan C. Slade, 
  • Dana Jazayeri, 
  • Louise Shaw, 
  • Matthew Knight, 
  • Cathy Jones, 
  • Anne-Marie Hill, 
  • Meg E. Morris

PLOS

  • Published: April 27, 2022
  • https://doi.org/10.1371/journal.pone.0266797
  • Reader Comments

Table 1

In hospitals, patient falls prevention education is frequently delivered by nurses and allied health professionals. Hospital falls rates remain high globally, despite the many systems and approaches that attempt to mitigate falling. The aim of this study was to investigate health professional views on the enablers and barriers to providing patient falls education in hospitals. Four focus groups with 23 nursing and allied health professionals were conducted at 3 hospitals. Three researchers independently coded the data and findings were analysed thematically with a descriptive qualitative approach to identify and develop themes according to barriers and enablers. Barriers included (i) limited interprofessional communication about patient falls; (ii) sub-optimal systems for falls education for patients and health professionals, and (iii) perceived patient-related barriers to falls education. Enablers to providing patient falls education included: (i) implementing strategies to increase patient empowerment; (ii) ensuring that health professionals had access to effective modes of patient education; and (iii) facilitating interprofessional collaboration. Health professionals identified the need to overcome organisational, patient and clinician-related barriers to falls education. Fostering collective responsibility amongst health professionals for evidence-based falls prevention was also highlighted.

Citation: Heng H, Kiegaldie D, Slade SC, Jazayeri D, Shaw L, Knight M, et al. (2022) Healthcare professional perspectives on barriers and enablers to falls prevention education: A qualitative study. PLoS ONE 17(4): e0266797. https://doi.org/10.1371/journal.pone.0266797

Editor: Saravana Kumar, University of South Australia, AUSTRALIA

Received: January 26, 2021; Accepted: March 28, 2022; Published: April 27, 2022

Copyright: © 2022 Heng et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the manuscript and the tables.

Funding: MEM, DK, A-MH received a grant (number GNT1152853) from the National Health and Medical Research Council ( https://www.nhmrc.gov.au/ ). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Health professionals have a key role in mitigating falls in hospitals [ 1 , 2 ]. This includes delivering multi-factorial interventions that include patient education, clinician training, rehabilitation, exercises, environmental modifications, and optimal hospital falls systems and policies [ 3 – 6 ]. Of these, patient education is key and has evidence for effectiveness for falls prevention in hospitals [ 7 , 8 ]. Nurses and allied health professionals deliver falls prevention education using face-to-face discussions with individuals or groups, brochures, pamphlets, posters, patient education and videos [ 9 ].

Hospital falls continue to be a challenging issue worldwide, ranging from 6 to 17 falls per 1000 bed days [ 8 , 10 , 11 ]. When patients fall, they are at risk of sustaining injuries such as fractures, intracranial bleeding and lacerations, which may lead to further complications [ 12 , 13 ]. People over the age of 65 years and those over the age of 50 years with a co-morbidity are at greater risk [ 14 ]. Risk factors for hospital falls include advanced age, a previous history of falls, cognitive impairment and multi-morbidity [ 15 , 16 ].

To empower patients to prevent falling whilst in hospital, a patient-centred approach can be used [ 17 , 18 ]. Engaging patients in the decision making processes about their own health and wellbeing makes them more likely to adhere to recommended falls prevention strategies [ 19 , 20 ]. The content of the falls education program and mode of delivery also require careful consideration [ 21 ]. Many previous studies on patient falls education in hospitals did not take into account educational design or the quality of the education provided to patients [ 9 ]. When this was done effectively, patients and health professionals were empowered to prevent falls [ 2 , 8 , 22 ]. Patient falls education was shown to improve patient knowledge and awareness of falls mitigation strategies, as well as health professional motivation for delivering education [ 2 , 22 ]. Well-designed education has the potential to empower patients by increasing self-efficacy and encouraging them to engage with falls prevention strategies [ 22 ].

Since nursing and allied health professionals are the main providers of falls prevention education in hospitals, it is imperative for them to deliver patient education effectively, with consideration to evidence-based approaches. While there have been studies of health professional experiences with patient falls in hospital [ 23 , 24 ], and health professional views of patient education [ 25 , 26 ], there has not yet been a study exploring health professional views about hospital patient falls education. A greater understanding of health professional views can help to facilitate implementation of evidence-based practice [ 27 , 28 ]. Identifying health professional views is necessary to facilitate a process where their needs are met and therefore lead to them being more willing to engage with implementing evidence-based approaches [ 29 , 30 ]. Aligning evidence-based strategies with their views is likely to foster more engagement and adherence [ 31 ]. To reduce hospital falls rates, it is important to understand health professional beliefs about how to design and deliver effective patient education.

The aims of this study were to: (i) explore health professional views of the enablers and barriers to delivering evidence-based patient falls prevention education programs in hospitals; and (ii) understand health professional perceptions of appropriate educational delivery for hospitalised patients.

Semi-structured focus groups with nursing and allied health professionals were conducted at three large Australian hospitals. To gain a deep understanding of health professional views and experiences of hospital falls prevention education, an explorative and descriptive qualitative design was selected [ 32 , 33 ]. Thematic analysis was used to identify patterns and ideas across participant data [ 32 , 34 ]. A descriptive qualitative approach to data analysis allowed major themes to be captured [ 17 ]. A focus group design was chosen as it allowed for new insights that can arise from participant interactions [ 35 , 36 ].

Recruitment and sampling

A purposive sampling methodology was used to recruit participants at one acute and two rehabilitation hospitals. The research team liaised with allied health managers and nurse unit managers for recruitment and the managers distributed participant information statements to potential participants. Participants were reassured that there was no compulsion for them to participate and declining to participate would not disadvantage them in any way.

Registered nurses or allied health professionals were eligible to participate if they worked in hospitals. Health professionals who worked in non-inpatient settings were excluded. Prior to commencing the focus groups, the health professionals completed a questionnaire on their occupation, main area of work, clinical experience, and qualifications.

Data collection

Once informed consent was obtained, focus groups were conducted at a convenient time for the stakeholders at each hospital site. The interview questions were developed with expert advice from members of the study team and after considering the analysis from a scoping review ( Table 1 ) [ 9 ]. The interview aimed to obtain health professional views on the enablers and barriers to evidence-based patient falls education. Interviews were semi-structured with the interviewer using the list of questions as a guide. Each focus group interview was audio-recorded and transcribed verbatim by a third-party transcription service. To ensure anonymity, each participant was de-identified with a number used in all transcripts and questionnaires.

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https://doi.org/10.1371/journal.pone.0266797.t001

An experienced qualitative researcher (SCS) facilitated the focus groups and another researcher (HH) took notes to capture additional observations and non-verbal responses. Members of the research team conducted data analysis (HH, DK, SCS, MEM), and provided clinical expertise and advised on research design and implementation (MEM, DK, DJ, MK, CJ, A-MH, LS). None of the research team had associations with the participants. All researchers had a background in healthcare which may result in pre-existing views about barriers and enablers to hospital falls prevention. These views were acknowledged and carefully managed by reflection and discussions in meetings during data collection and analysis.

Data analysis

The data were analysed thematically to identify patterns and develop themes [ 32 ]. Following the transcription of audio-recordings, the audio files and transcribed documents were compared to ensure accuracy. Three researchers (SCS, HH and DK) independently coded the data and identified categories and preliminary themes using a template based on the structure of the interview questions that were focused on barriers, enablers, and educational delivery. An iterative audit trail to ensure rigour of the analysis was undertaken. Findings were discussed and documented at each stage via video-conferencing or face-to-face meetings. Spreadsheets, documents, and tables were used to present coded data. If there were differences in opinion, another researcher (MEM) was consulted to achieve consensus. Participant quotes were used to generate final themes and sub-themes. Some examples are provided in the textboxes in the results section of this manuscript.

To minimise the risk of bias and promote study rigour, the following steps were followed: (i) we documented an a priori methodology; (ii) two or more members of the research team conducted data analysis; (iii) accurate recording and transcription of audio data; (iv) only health professionals with relevant experiences of hospital falls prevention were recruited; and (v) emerging themes were linked back to relevant participant quotes [ 37 , 38 ].

The study was approved by the La Trobe University Human Research Ethics Committee (HEC19373) and was registered in the Australian New Zealand Clinical Trials Registry (ACTRN12620000033943).

Participant characteristics

Four focus groups were conducted, with a total of 23 participants. Two focus groups comprised rehabilitation nurses (n = 7) and the other two groups included allied health professionals (n = 16) such as physiotherapists (n = 9), occupational therapists (n = 4) and allied health assistants (n = 3). The average years of clinical experience for the health professionals was 9.6 (SD 7.56, range 1–30). The average duration of the focus groups was 50.6 minutes (SD 8.4). Table 2 summarises participant characteristics.

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https://doi.org/10.1371/journal.pone.0266797.t002

Two overarching themes were identified from the qualitative analysis. The first pertained to perceived barriers to providing and implementing patient falls education that were: (i) sub-optimal systems for falls education for patients and health professionals; (ii) perceived patient-related barriers to evidence-based falls education; and (iii) limited interprofessional communication about patient falls. The second related to health professional views on how best to facilitate enablers to provide patient falls education. This incorporated sub-themes on: (i) facilitating interprofessional teamwork and collaboration; (ii) implementing strategies to increase patient empowerment; and (iii) selecting effective modes of education delivery.

Theme 1: Barriers to the provision of patient falls education

1.1 sub-optimal systems for falls education for patients and health professionals..

Many participants (n = 14) identified barriers at an organisational level, citing inconsistencies in clinical practice. These included variations in the content and design of falls education programs, differences in documenting falls and falls risk, and disparities in falls prevention education and communication between hospital sites, professions, and patients ( Box 1 ). A third of participants viewed communication about falls prevention as being inconsistent between hospital sites. One example was differing organisational policies where patients were given non-slip socks to prevent falls in an acute setting yet encouraged to wear sturdy footwear to prevent falls in a sub-acute setting. One clinician highlighted that, due to hospital policy, falls prevention strategies were often broadly implemented using standard methods instead of being individualised to the needs of patients ( Box 1 ).

Box 1. Sub-optimal systems for falls education for patients and health professionals

“Often there’s discrepancies between what we’ve documented, what’s documented on the progress notes, and then what’s documented by non-therapy staff as to what the patient’s mobility is” Focus group 1 , participant 1 (physiotherapist)

“Communication is definitely something that fails because of time. We’re all under a lot of pressure and the same for nursing, and at certain times of the day they’re under more pressure.” Focus group 4 , participant 23 (allied health assistant)

“We assess a patient for admission…there is a lot for us to document in an admission … along with doing observations…There’s a lot to it and…they’ll have another five patients. So, you need to look after the other five patients, but then also sit down and spend time educating the patient on falls or discussing falls or–when would you have the time?” Focus group 3 , participant 16 (nurse)

“Patients who clearly aren’t mobilising, like one of the patients on my ward at the moment has just had a fall but has never been referred to physio [for education]. But in all the notes there’s been supervision even though she was at home alone. Or inconsistent documentation about what the mobility status is.” Focus group 1 , participant 9 (physiotherapist)

“If someone’s admitted through ED at a weekend, for example, if they’ve come from a nursing home sometimes it’s not very accurate what their baseline is. And it’s just a case of phoning up the nursing home and asking the staff what exactly their status is before you go and assess them. But they may not have been done and then staff might have tried to get them up in the meantime” Focus group 1 , participant 10 (physiotherapist)

“We’re supposed to do the FRAT but I’m not following that FRAT score myself anymore. I’m just using my clinical judgement whether this patient’s low, moderate, or high falls risk” Focus group 4 , participant 20 (occupational therapist)

“A universal policy that people, every staff member adheres to patients walking with covered shoes with a good grip. I think that’s probably what we should be doing but I’m not sure if that’s universally adopted or implemented in a really clear way across nursing, OT, physio” Focus group 4 , participant 18 (physiotherapist)

“We no longer give out grip socks here, but they’ll come from the acute hospitals with grip socks.” Focus group 2 , participant 11 (nurse)

“You had patients who had shoes, who could clearly put those shoes on but because of the policy they were almost not forced, but they were pressured into wearing grip socks and these patients are about 30 years of age, 45 years of age. And it was just to tick a box in the campaign.” Focus group 1 , participant 1 (physiotherapist)

“they [physiotherapists] don’t run any education. They assess a patient with how safe they are with mobility… But the occupational therapist is looking at the bigger picture for education and discharge planning” Focus group 3 , participant 16 (nurse)

Another barrier was a perceived lack of capacity, time, or staff resources to deliver evidence-based falls prevention education. A third of the participants reported that discrepancies existed in communication between professions and between patients. This variability was sometimes associated with time constraints or staffing ratios. Another organisational barrier related to documentation, which was considered to be time consuming. It was also reported that falls prevention strategies were inconsistent across settings. Examples of quotes on these themes are presented in Box 1 .

1.2 Perceived patient-related barriers to evidence-based falls education.

Almost half of all participants identified patient-related factors as a barrier to providing falls education ( Box 2 ). Some health professionals reported a lack of insight by patients about their falls risk which limited their receptiveness to falls prevention education. Health professionals noted that, due to the desire to maintain dignity or independence, or to not “cause trouble” for staff, some patients did not follow recommended falls education advice. This could result in patients avoiding using the call bell, not waiting for assistance, or avoiding using recommended mobility aids. Systemic issues and organisational barriers could also contribute to slow call bell responses. Five of the health professionals reported their view that some patients choose to disregard the falls education due to their beliefs, situation or personality ( Box 2 ).

Box 2. Perceived patient-related barriers to evidence-based falls education

“…That perception that they don’t want to disturb the nurse. They don’t want to press the buzzer” Focus group 2 , participant 13 (nurse)

“They’re not wanting to give up their independence. So, their reluctance to pull the bell because they’ve been independent. They feel like a burden. They’re not wanting to pull the bell so they might attempt to–even though they might not be safe” Focus group 1 , participant 2 (physiotherapist)

“Sometimes it’s hard to tell if language barrier … is an issue … in the moment or if it’s a personality thing, or a cultural thing. Again, sometimes men just don’t seem to like being told by women what to do. … Sometimes women don’t like to be told.” Focus group 4 , participant 22 (allied health assistant)

“They might not realize that they are at risk of having a fall, so they might be just really confident. Their mobility has been fine at home before hospital. They don’t realize that things have changed…I think just lack of insight probably” Focus group 3 , participant 17 (nurse)

“Some of the younger ones that can have really poor mobility think they’re a lot better than what they are. And they don’t want to use those because they think they’re not old enough for aids and those types of things” Focus group 1 , participant 8 (occupational therapist)

“They’ve [patients] definitely been given that information time and time again, and have chosen not to take it on-board…then we’re left at that kind of path of where do we go from here. We’ve given them as much information as we can, we’ve reiterated, and they definitely have the same outcome time and time. So, it’s one of things that how much can you really get a patient to do if they’re just not willing to participate with your instructions.” Focus group 1 , participant 5 (physiotherapist)

“There’s been a few that have fallen like that…they want to go to the toilet and…they’ll get embarrassed if they do it in their bed or their seat” Focus group 1 , participant 8 (occupational therapist)

1.3 Limited interprofessional communication about patient falls.

A recurring theme was a perceived shortfall in interprofessional communication and health professional collaboration ( Box 3 ). Over half of the participants reported that breakdowns in communication between professions was a major barrier to providing patient falls education. These breakdowns appeared to occur in both verbal and written communications. Two thirds of participants reported discrepancies in documentation about falls in medical records and other hospital documents. Of these participants, 6 allied health professionals spoke about the inconsistencies between health professional groups in documentation related to the functional and mobility status of patients. Two other allied health professionals reported differences in documentation between nursing shifts. The participants also noted discrepancies in written documentation between professions or reported a lack of collaborative discussion about falls risk and mitigation at handover. Three allied health professionals felt that some staff overlooked or disregarded their written recommendations about falls prevention. Two nurses held the view that formal falls education was the role of allied health professionals. One physiotherapist advised that all staff should be responsible for responding to patient needs to reduce their falls risk. This shortfall in teamwork and role clarification was viewed as a barrier to providing falls education ( Box 3 ). Several clinical-related attitudinal factors were also highlighted by health professional participants. There was a perception of an over-reliance on processes that could lead to complacency. Two participants felt that completing forms could become routine and limit clinical judgements about the needs of individual patients ( Box 3 ).

Box 3. Limited interprofessional communication about patient falls

“I don’t think the progress notes are necessarily followed. That’s the legal communication document, but people often refer to their own handovers and that interpretation of what’s written in the progress notes is not always [correct]… they’ve got their own interpretation of it.” Focus group 1 , participant 1 (physiotherapist)

“We tell them [patient] that they should be encouraged to be independent as part of their physical conditioning being in a hospital. But then you read the nursing notes that say … ‘maximum assistance provided, or full assistance provided’” Focus group 4 , participant 21 (occupational therapist)

“The patient is made aware of what they can and what they should ideally be doing. But it’s not necessarily always followed. And sometimes that information’s not handed over to the staff over the course of the day” Focus group 1 , participant 1 (physiotherapist)

“Another element of why falls happen is the communication between the documentation and the staff. Because there can be just verbal communication from one staff member–I’m referring to nursing staff–at the end of a shift and then there can just be a little bit of miscommunication” Focus group 1 , participant 5 (physiotherapist)

“I think we all know it [falls education], and we just leave it to the physios to do” Focus group 2 , participant 11 (nurse)

“I was highlighting to everybody in the office that…everyone is capable of responding to that falls alarm. If that person had a fall and the research says that they may die within the next two years, that’s all our responsibility.” Focus group 1 , participant 9 (physiotherapist)

“They have to go through it [falls risk FRAT form] and they have to tick all the things like age and medications…But I don’t know if it just becomes: “we need to do this form for admission, tick all the boxes” … whether it’s actually triggering a thought about it.” Focus group 1 , participant 9 (physiotherapist)

“Some clinicians are very black and white, just based on the numbers, hence, you’re a high falls risk when they’re actually moderate. … I think it’s better to utilise your own clinical judgement and make that call” Focus group 4 , participant 20 (occupational therapist)

Theme 2: Enablers to the provision of patient falls education

2.1 facilitating interprofessional teamwork and collaboration..

More than a third of participants identified the value of an interprofessional approach to facilitating falls prevention education. Nurses and allied health professionals advised that interprofessional teamwork facilitated consistent and frequent patient education. They expressed a view that, with effective communication, health professionals could address falls risk factors in a more united and holistic manner and have a collective approach to consistent falls education. Three allied health professionals advised regularly consulting nurses and other health professionals about the patient’s functional status to form a holistic view of their needs. Two nurses reported that they worked with the multidisciplinary team to identify falls prevention strategies for complex patients. This collaborative practice approach promoted collective responsibility and patient-centred care to ensure that individual patient needs were addressed by the team ( Box 4 ).

Box 4. Facilitating interprofessional teamwork and collaboration

“Falls needs to be taken as a holistic view where the team gets involved around the patient’s fall. This is not targeted at any one type of clinician but as the team looking after the patient. If they’ve come with a fall that it should trigger a pathway of thinking or risk assessment about this patient’s holistic presentation” Focus group 1 , participant 9 (physiotherapist)

“To me it’s the communication. I speak to the nurses, what do they [patients] do…what are they doing and that’s where falls education happens as well.” Focus group 4 , participant 20 (occupational therapist)

“Here we’re lucky with all our allied health staff, because…they will reiterate what we say.” Focus group 2 , participant 11 (nurse)

“It’s about us nursing staff communicating with the team and the doctors and the allied health to see if there is something that we’re not using at this point and see what other options we have for that patient.” Focus group 3 , participant 16 (nurse)

“Sometimes during handover there would be a highlight of, “Look, you know, we’re not happy with the mobility of this patient.” Physio will be asked to assess, and then we’ll wait for their assessment, and then it has to be handed over. And everybody that is on that shift has to know, just in case.” Focus group 2 , participant 15 (nurse)

2.2 Implementing strategies to increase patient empowerment.

The health professionals identified patient empowerment as a strong enabler to education. More than two thirds recommended a focus on empowering patients to improve the uptake of falls education. They suggested this could be achieved by individualising the education, encouraging patients to reflect on their falls risk and ensuring the education was relevant to the patient’s situation. Health professionals felt that this allowed for deeper learning and an increase in an adoption of falls prevention strategies. In addition, there was agreement that education should be continuous throughout a patient’s stay. The majority felt that empowering patients across the continuum of care could lead to improved outcomes ( Box 5 ).

Box 5. Implementing strategies to increase patient empowerment

“Empowering them with the knowledge of why, not just this is what’s happening.” Focus group 4 , participant 23 (allied health assistant)

“I think they need to know why they’re a falls risk because then they can–if they understand it, they’re more likely to comply because they will know why rather than just, ‘I’m a falls risk. I don’t agree with that. I’m just going to walk.’” Focus group 3 , participant 17 (nurse)

“The campaign’s very much like a very broad brush that’s used…the next campaign it shouldn’t take that approach, it should be based on what’s needed for that particular patient.” Focus group 1 , participant 1 (physiotherapist)

“Sometimes following up and just asking them how they felt about it [education] afterwards and things like that…just asking questions after it and seeing how they respond, and judging that way.” Focus group 1 , participant 7 (allied health assistant)

“We get them to identify the falls risks and then we have another discussion about what can we do to fix that risk… So they’ll come up with ideas, so they’re thinking about it more than just us telling them.” Focus group 1 , participant 8 (occupational therapist)

“It depends on therapists’ clinical judgements whether these patients will benefit from falls prevention groups or whether just one on one… Behaviour, personality, whether they actually interact in discussions. I think it’s really quite personal” Focus group 4 , participant 20 (occupational therapist)

“I think that the reiterating of knowledge throughout their entire stay through rehab…constant falls prevention education is really beneficial for patients if we’re incorporating it into everything we’re doing” Focus group 1 , participant 4 (occupational therapist)

“I think the content of the education’s one thing, I think you need to observe how they’ve taken the education on… You’ve got to actually observe and then document implemented safe technique, so that you’ve documented that you’ve not only imparted the education but that they’ve changed what they were doing in order to change” Focus group 4 , participant 18 (physiotherapist)

2.3 Selecting effective modes of educational delivery.

The way in which education was delivered was perceived to be an important facilitator for effective falls mitigation. This included the nature of the messaging about falls prevention and the methods that health professionals used for falls education delivery. Over two thirds of participants reinforced the importance of consistent and frequent provision of education across and within professions, and throughout the continuum of care. Ten supported verbal reinforcement of falls education, believing that reiterating the education emphasised its importance as well as encouraging knowledge retention.

There were different suggestions for methods of delivery. One third of participants recommended making the education interactive to increase engagement with patients. Some suggested asking questions to encourage self-reflection and others recommended group education to share experiences and learn from each other. Another mode of education was the use of falls risk reminders. A third of participants felt that these reminders could assist in reinforcing the education. Six participants reported that involving families to reiterate falls education had beneficial effects. The families were then able to reinforce the education in hospital and at home, encourage adherence to falls prevention strategies and monitor patients for risk-taking behaviours ( Box 6 ).

Box 6. Selecting effective modes of educational delivery

“Every time I see a patient, I mention wearing their shoes, so always ask them to wear proper shoes.” Focus group 4 , participant 19 (physiotherapist)

“Some of the patients have seen the falls DVD two or three times and they go, “Not this again.” But then when I talk to them later, they pick up something else that they haven’t picked up on the other ones…Familiarity breeds more knowledge when they see it a few times and they pick up different things, and it sinks in. They see it once and it’s gone.” Focus group 1 , participant 8 (occupational therapist)

“More of an interactive coaching interview, you know how you were saying that people come up with the ideas themselves they’re more likely to implement them or be responsive to them. So rather than just giving an interview and telling the person maybe making them reflect on their own current practices or talk about previous falls, what maybe could have led to that not happening. More coaching” Focus group 1 , participant 9 (physiotherapist)

“We run a patient falls group and I’ve found…smaller patient groups it’s much more interactive. They actually share their experience about falls.” Focus group 4 , participant 20 (occupational therapist)

“Let them see the falls prevention DVD and then we’ll talk about what they saw, what do they recall, and talk about the broader aspects of it as well” Focus group 1 , participant 8 (occupational therapist)

“if someone’s got a supervision tag then every person who sees that patient can reinforce the same message around the guidelines that they’re supposed to be adhering to…maybe in the middle of the night they will call the nurse before they get up and go to the loo. … So maybe it enables more consistency across the staff." Focus group 4 , participant 18 (physiotherapist)

“some, or most of our patients have either short-term memory loss, so if the family is there, we educate the family…we have an hourly round, so we find later on we iterate again, because they already forgotten.” Focus group 2 , participant 13 (nurse)

“I think talking to family members too. And they’ve probably got a better idea of how they’ve been going at home, whether they’ve been falling at home. Talking about history. If your family member’s there, it’s usually a lot better to get an idea of what they’ve been like mobility-wise at home… and then including the family member when we’re talking about falls prevention, things to do at home.” Focus group 1 , participant 8 (occupational therapist)

Health professionals have a key role in mitigating hospital falls and delivering evidence-based patient education [ 39 , 40 ]. Our focus groups showed that nurses and allied health professionals are usually aware of the enablers and barriers to providing falls education. They can also generate different ideas on how best to facilitate patient falls education. Nevertheless, there were systemic issues and variability in practice that compromised their ability to consistently implement evidence based, patient-focussed, inter-professional falls prevention education. In addition, health professionals sometimes consider themselves to be the experts in falls prevention and there remains scope for further consumer engagement and co-design of education programs [ 1 , 9 ].

Inconsistencies in clinical practice was a major barrier, as with previous reports [ 41 – 43 ]. Heng et al. [ 44 ] reported inconsistencies in falls education, content and delivery which limited the ability of patients to understand their risk of falling during an admission. Time constraints and lack of staffing capacity and resources were other challenges, in agreement with Ackerman et al. [ 45 ], Keyworth et al. [ 43 ] and Svavarsdóttir et al. [ 25 ]. There was often over-reliance on processes and forms which can take the focus away from clinical judgement [ 46 ].

Another area that health professionals identified for improvement was the follow up of patients after the initial provision of falls education. Health professionals recognised that repeated messaging was needed, although they cited several barriers to doing so and highlighted the complex nature of translating evidence-based knowledge into practice [ 47 , 48 ]. Clinician follow-up has been shown by Berger et al. [ 49 ] and Beagley [ 50 ] as one way of reinforcing patient education, together with visual reminders and family involvement in reinforcing falls education messages.

Another barrier to providing falls prevention education was lack of communication between different health professionals. Lee et al. [ 41 ] reported that inconsistencies in education and communication can undermine the message of falls prevention and increased falls risk. Health professionals who provided hospital falls prevention education in the current study also identified inconsistencies between health professional assessments of mobility that increased falls risk. Inconsistent instructions to patients have likewise been shown by Hill et al. [ 51 ] to increase falls risk. Discrepancies in documentation and poor clinical handover practices can also be associated with adverse events [ 52 , 53 ], including an increase in falls [ 54 , 55 ]. In agreement with our focus groups, Foronda et al. [ 56 ] advised that interprofessional communication is paramount in ensuring safe patient outcomes.

Limited collaboration and teamwork between professions were further barriers to patient falls education. Interprofessional collaborative practice can improve patient outcomes and elevates health organisations and systems [ 57 – 59 ]. Interprofessional collaborative practice fosters a climate of safety and improved clinical practice [ 60 – 62 ]. Interprofessional education, where two or more professions learn with, from and about each other [ 63 ], can be a way to foster teamwork, collaboration, communication and patient-centred care [ 57 , 64 , 65 ]. McKenzie et al. [ 66 ] reported that interprofessional education resulted in improved falls screening and prevention. Wheeler et al. [ 61 ] demonstrated that evidence-based interprofessional education for falls prevention had a positive impact on the clinical practice of physiotherapists and occupational therapists. Health professionals often face challenges when implementing interprofessional education, such as having separate professional cultures [ 67 ], logistical barriers [ 68 ], limited shared resources in training [ 69 ], and varying clinical practice demands [ 70 ]. By ensuring consistency of patient education content across professions through interprofessional collaborative practice and interprofessional education, the message of falls prevention can be reinforced [ 71 , 72 ].

Patient-centred factors also need to be taken into consideration. Patients may not always be aware of their falls risk or changes in mobility despite receiving falls education [ 73 , 74 ]. They can also have a fear of embarrassment or a reluctance to burden staff, or have a false sense of security that adversely affects adherence to recommended strategies [ 22 , 75 ]. According to Haines et al. [ 76 ], this can result in patients taking unnecessary risks which increase falls. Empowering patients to prevent their own falls across the continuum of care and within routine activities of daily living was a key recommendation. Involving patient representatives in the co-design and implementation of interventions and making education relevant, interactive and individualised allows for patients to better engage with the health professional and the education [ 77 , 78 ]. Similar health behaviour changes through patient empowerment have also been identified by Joseph-Williams et al. [ 79 ] and Michie et al. [ 80 ]. As with Heng’s trial on patient perspectives [ 74 ], the health professionals in the current study identified frequent and consistent provision of patient education to be a key determinant of hospital falls. Likewise, in the design of future interventions, there is a need to consider initiatives that focus on improving collaboration and teamwork, along with being more patient-centred and tailoring educational materials to individual needs.

The modes of educational delivery were perceived to be a key enabler for effective falls education. In line with participant views, group education [ 81 , 82 ], interactive education [ 83 ], and encouraging self-reflection [ 84 ] have been found to improve engagement and reinforce learning. Involving families when delivering education can also lead to better patient outcomes [ 85 ]. Findings about the delivery of education are a key determinant of the success of falls prevention programs in hospital [ 4 ]. However, in this study there was a lack of focus on the quality of educational design. According to Heng et al. [ 9 ], the quality of educational design can be linked with improved hospital falls outcomes. As shown by Shaw et al. [ 1 ], educational design is a powerful tool to influence the success of falls prevention training for health professionals and patients alike.

There were several limitations of this study. Primarily, the focus groups were limited to English speaking participants in hospitals in one state of Australia. Most participants were based in sub-acute hospital wards and the findings might not be generalisable to other populations or other countries. Also, this study focused on hospital education programs and might not be generalisable to outpatients or community populations. There are inherent limitations of using focus groups as a means for collecting data. For example, health professionals might have varied levels of employment in their institution and power imbalances can occur within groups [ 86 ]. These factors need to be considered in the design of future studies. There is also a need to further explore the growing body of work about dignity of risk, particularly in respect to falls management in hospitals. The strengths of this study included representation from different health professions and the high level of expert falls contextual knowledge of participants. Trustworthiness was strengthened by experienced moderators who were also experts in the field.

Health professionals working in hospital settings recognised enablers and barriers to providing patient falls prevention education. Managing inconsistencies in clinical practice, communication barriers and professional silos were hurdles. Enablers included carefully designed interactive education resources tailored to individual needs of patients, as well as implementation of patient-centred hospital processes to empower the patients to gain knowledge. Systems to foster collective responsibility amongst health professionals to create a culture of vigilance regarding preventing hospital falls were also key.

Supporting information

S1 checklist. consolidated criteria for reporting qualitative studies (coreq): 32-item checklist..

https://doi.org/10.1371/journal.pone.0266797.s001

Acknowledgments

We thank the participants who generously gave their time to participate in this research, as well as Linda Shelley and Penny Byers-Timms for supporting this research project.

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Reducing Fall Risk in Older Adults

Haddad, Yara K. PharmD, MPH; Bergen, Gwen PhD, MPH, MS; Luo, Feijun PhD

Yara K. Haddad is a consultant pharmacist and Gwen Bergen is a behavioral scientist in the Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention in Atlanta. Feijun Luo is an economist in the Division of Analysis, Research, and Practice Integration, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. Contact author: Yara K. Haddad, [email protected] . The authors have disclosed no potential conflicts of interest, financial or otherwise. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Evidence supports addressing medication management.

More than one in four American adults ages 65 and older reported falling and one in 10 reported a fall-related injury in 2014. 1 Among older adults, falls account for approximately 60% of all injury-related ED visits and over 50% of injury-related deaths annually. 2 Rates of medically treated falls are rising and the older adult population is increasing, 1 which will result in a significant burden on the health care system if more is not done to prevent falls. Although falls among older adults are common, they can be prevented by targeting modifiable risk factors such as vestibular disorders, postural hypotension, vision impairment, foot problems, and medication adverse effects. Effective evidence-based interventions include participation in physical therapy or an exercise program, managing postural hypotension, referral to vision specialists or podiatrists, and medication review and management. 3

Medication use is prevalent in older adults, with four out of five taking at least one prescription medication daily and over a third taking five or more. 4 According to unpublished data from the Centers for Disease Control and Prevention (CDC), more than half of all older adults (53%) used at least one medication in 2013 whose adverse effects were linked to falls. This makes medication management a key component in reducing fall risk. Psychoactive medications used to treat psychosis, anxiety, depression, pain, and sleep disorders affect the central nervous system and can cause adverse effects that increase the risk of falls. According to the unpublished CDC data, older women are at an increased risk for medication-related falls compared with older men because women use more medications associated with falls (57% versus 49%). Specifically, older women use more opioids (37% versus 33%) and benzodiazepines (19% versus 11%).

In response to the need to prevent falls and fall-related injuries in older adults, the CDC has developed the Stopping Elderly Accidents, Deaths, and Injuries (STEADI) initiative to guide nurses and other health care providers in (1) screening older adults for fall risk, (2) assessing modifiable risk factors, and (3) intervening to reduce risk by using effective clinical and community strategies (see Figure 1 ). On the CDC's STEADI web page ( www.cdc.gov/steadi ), nurses can access the STEADI Older Adult Fall Prevention Online Training for Providers, which offers an overview of the STEADI initiative and free continuing education for nurses; medication management resources including the SAFE (screen, assess, formulate, and educate) Medication Review Framework for a targeted medication review; and the Medications Linked to Falls fact sheet.

F1

Nurses play an important role in reducing patients’ fall risk by identifying medications associated with increased fall risk; educating patients on the risks and benefits of their medications; and working with pharmacists and prescribers to stop or switch medications, or reduce the doses of medications, associated with falls. Minimizing older adults’ exposure to psychoactive medications is an important intervention to improve health outcomes and decrease falls.

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Prevention of Falls in Older Adults

  • 1 Associate Editor, JAMA
  • Editorial Preventing Falls in Older Persons David B. Reuben, MD; David A. Ganz, MD, PhD JAMA
  • US Preventive Services Task Force USPSTF Recommendation: Interventions to Prevent Falls in Community-Dwelling Older Adults US Preventive Services Task Force; Wanda K. Nicholson, MD, MPH, MBA; Michael Silverstein, MD, MPH; John B. Wong, MD; Michael J. Barry, MD; David Chelmow, MD; Tumaini Rucker Coker, MD, MBA; Esa M. Davis, MD, MPH; Carlos Roberto Jaén, MD, PhD, MS; Marie Krousel-Wood, MD, MSPH; Sei Lee, MD, MAS; Li Li, MD, PhD, MPH; Goutham Rao, MD; John M. Ruiz, PhD; James Stevermer, MD, MSPH; Joel Tsevat, MD, MPH; Sandra Millon Underwood, PhD, RN; Sarah Wiehe, MD, MPH JAMA
  • US Preventive Services Task Force USPSTF Review: Interventions to Prevent Falls in Older Adults Janelle M. Guirguis-Blake, MD; Leslie A. Perdue, MPH; Erin L. Coppola, MPH; Sarah I. Bean, MPH JAMA

Falls are the leading cause of injury in adults aged 65 years or older.

Falls are common among older adults. In a 2018 survey, more than one-fourth of US older adults living in the community reported at least 1 fall in the past year. A serious fall in an older adult can result in injury (such as hip fracture) that causes decreased independence and decreased quality of life. The risk of falling increases with age for many reasons, including overall weakness and frailty; problems with balance, cognition, and vision; certain medications; acute illness; and other environmental hazards. Those who have fallen in the past are at high risk of falling again.

How Can Primary Care Clinicians Aim to Prevent Falls in Older Adults?

To answer this question, the US Preventive Services Task Force (USPSTF) reviewed many studies about interventions for older adults living in the community (not in a nursing home or other institutional care setting). These interventions include exercise therapy (such as working on gait, balance, and leg muscle strengthening), environmental assessments, medication reviews, and multifactorial interventions, which involve creating a customized plan based on individual risk factors. Among all of these interventions, exercise therapy was found to be most beneficial.

Pros and Cons of Trying to Prevent Falls in Older Adults

The pros of trying to prevent falls is avoiding potentially serious injuries or death. Although current evidence suggests that exercise therapy helps decrease falls and injury from falls, no studies have shown a direct link between any interventions to prevent falls and overall risk of death.

The cons of trying to prevent falls include injury (including falling itself) from exercise therapy; however, this risk is small.

Should Primary Care Clinicians Provide Interventions to Prevent Falls?

The USPSTF recommends exercise interventions to prevent falls in community-dwelling adults aged 65 years or older who are at increased risk of falls. For multifactorial interventions, there may be a small benefit, and primary care clinicians should consider multifactorial interventions for patients at higher risk of falling on a case-by-case basis.

For More Information

US Preventive Services Task Force www.uspreventiveservicestaskforce.org/uspstf/topic_search_results?topic_status=P

To find this and other JAMA Patient Pages, go to the Patient Information collection at jamanetworkpatientpages.com .

Published Online: June 4, 2024. doi:10.1001/jama.2024.9713

Conflict of Interest Disclosures: None reported.

Source: US Preventive Services Task Force. Interventions to prevent falls in community-dwelling older adults: US Preventive Services Task Force recommendation statement. JAMA . Published June 4, 2024. doi:10.1001/jama.2024.8481

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  • Published: 03 July 2024

The impact of evidence-based nursing leadership in healthcare settings: a mixed methods systematic review

  • Maritta Välimäki 1 , 2 ,
  • Shuang Hu 3 ,
  • Tella Lantta 1 ,
  • Kirsi Hipp 1 , 4 ,
  • Jaakko Varpula 1 ,
  • Jiarui Chen 3 ,
  • Gaoming Liu 5 ,
  • Yao Tang 3 ,
  • Wenjun Chen 3 &
  • Xianhong Li 3  

BMC Nursing volume  23 , Article number:  452 ( 2024 ) Cite this article

135 Accesses

Metrics details

The central component in impactful healthcare decisions is evidence. Understanding how nurse leaders use evidence in their own managerial decision making is still limited. This mixed methods systematic review aimed to examine how evidence is used to solve leadership problems and to describe the measured and perceived effects of evidence-based leadership on nurse leaders and their performance, organizational, and clinical outcomes.

We included articles using any type of research design. We referred nurses, nurse managers or other nursing staff working in a healthcare context when they attempt to influence the behavior of individuals or a group in an organization using an evidence-based approach. Seven databases were searched until 11 November 2021. JBI Critical Appraisal Checklist for Quasi-experimental studies, JBI Critical Appraisal Checklist for Case Series, Mixed Methods Appraisal Tool were used to evaluate the Risk of bias in quasi-experimental studies, case series, mixed methods studies, respectively. The JBI approach to mixed methods systematic reviews was followed, and a parallel-results convergent approach to synthesis and integration was adopted.

Thirty-one publications were eligible for the analysis: case series ( n  = 27), mixed methods studies ( n  = 3) and quasi-experimental studies ( n  = 1). All studies were included regardless of methodological quality. Leadership problems were related to the implementation of knowledge into practice, the quality of nursing care and the resource availability. Organizational data was used in 27 studies to understand leadership problems, scientific evidence from literature was sought in 26 studies, and stakeholders’ views were explored in 24 studies. Perceived and measured effects of evidence-based leadership focused on nurses’ performance, organizational outcomes, and clinical outcomes. Economic data were not available.

Conclusions

This is the first systematic review to examine how evidence is used to solve leadership problems and to describe its measured and perceived effects from different sites. Although a variety of perceptions and effects were identified on nurses’ performance as well as on organizational and clinical outcomes, available knowledge concerning evidence-based leadership is currently insufficient. Therefore, more high-quality research and clinical trial designs are still needed.

Trail registration

The study was registered (PROSPERO CRD42021259624).

Peer Review reports

Global health demands have set new roles for nurse leaders [ 1 ].Nurse leaders are referred to as nurses, nurse managers, or other nursing staff working in a healthcare context who attempt to influence the behavior of individuals or a group based on goals that are congruent with organizational goals [ 2 ]. They are seen as professionals “armed with data and evidence, and a commitment to mentorship and education”, and as a group in which “leaders innovate, transform, and achieve quality outcomes for patients, health care professionals, organizations, and communities” [ 3 ]. Effective leadership occurs when team members critically follow leaders and are motivated by a leader’s decisions based on the organization’s requests and targets [ 4 ]. On the other hand, problems caused by poor leadership may also occur, regarding staff relations, stress, sickness, or retention [ 5 ]. Therefore, leadership requires an understanding of different problems to be solved using synthesizing evidence from research, clinical expertise, and stakeholders’ preferences [ 6 , 7 ]. If based on evidence, leadership decisions, also referred as leadership decision making [ 8 ], could ensure adequate staffing [ 7 , 9 ] and to produce sufficient and cost-effective care [ 10 ]. However, nurse leaders still rely on their decision making on their personal [ 11 ] and professional experience [ 10 ] over research evidence, which can lead to deficiencies in the quality and safety of care delivery [ 12 , 13 , 14 ]. As all nurses should demonstrate leadership in their profession, their leadership competencies should be strengthened [ 15 ].

Evidence-informed decision-making, referred to as evidence appraisal and application, and evaluation of decisions [ 16 ], has been recognized as one of the core competencies for leaders [ 17 , 18 ]. The role of evidence in nurse leaders’ managerial decision making has been promoted by public authorities [ 19 , 20 , 21 ]. Evidence-based management, another concept related to evidence-based leadership, has been used as the potential to improve healthcare services [ 22 ]. It can guide nursing leaders, in developing working conditions, staff retention, implementation practices, strategic planning, patient care, and success of leadership [ 13 ]. Collins and Holton [ 23 ] in their systematic review and meta-analysis examined 83 studies regarding leadership development interventions. They found that leadership training can result in significant improvement in participants’ skills, especially in knowledge level, although the training effects varied across studies. Cummings et al. [ 24 ] reviewed 100 papers (93 studies) and concluded that participation in leadership interventions had a positive impact on the development of a variety of leadership styles. Clavijo-Chamorro et al. [ 25 ] in their review of 11 studies focused on leadership-related factors that facilitate evidence implementation: teamwork, organizational structures, and transformational leadership. The role of nurse managers was to facilitate evidence-based practices by transforming contexts to motivate the staff and move toward a shared vision of change.

As far as we are aware, however, only a few systematic reviews have focused on evidence-based leadership or related concepts in the healthcare context aiming to analyse how nurse leaders themselves uses evidence in the decision-making process. Young [ 26 ] targeted definitions and acceptance of evidence-based management (EBMgt) in healthcare while Hasanpoor et al. [ 22 ] identified facilitators and barriers, sources of evidence used, and the role of evidence in the process of decision making. Both these reviews concluded that EBMgt was of great importance but used limitedly in healthcare settings due to a lack of time, a lack of research management activities, and policy constraints. A review by Williams [ 27 ] showed that the usage of evidence to support management in decision making is marginal due to a shortage of relevant evidence. Fraser [ 28 ] in their review further indicated that the potential evidence-based knowledge is not used in decision making by leaders as effectively as it could be. Non-use of evidence occurs and leaders base their decisions mainly on single studies, real-world evidence, and experts’ opinions [ 29 ]. Systematic reviews and meta-analyses rarely provide evidence of management-related interventions [ 30 ]. Tate et al. [ 31 ] concluded based on their systematic review and meta-analysis that the ability of nurse leaders to use and critically appraise research evidence may influence the way policy is enacted and how resources and staff are used to meet certain objectives set by policy. This can further influence staff and workforce outcomes. It is therefore important that nurse leaders have the capacity and motivation to use the strongest evidence available to effect change and guide their decision making [ 27 ].

Despite of a growing body of evidence, we found only one review focusing on the impact of evidence-based knowledge. Geert et al. [ 32 ] reviewed literature from 2007 to 2016 to understand the elements of design, delivery, and evaluation of leadership development interventions that are the most reliably linked to outcomes at the level of the individual and the organization, and that are of most benefit to patients. The authors concluded that it is possible to improve individual-level outcomes among leaders, such as knowledge, motivation, skills, and behavior change using evidence-based approaches. Some of the most effective interventions included, for example, interactive workshops, coaching, action learning, and mentoring. However, these authors found limited research evidence describing how nurse leaders themselves use evidence to support their managerial decisions in nursing and what the outcomes are.

To fill the knowledge gap and compliment to existing knowledgebase, in this mixed methods review we aimed to (1) examine what leadership problems nurse leaders solve using an evidence-based approach and (2) how they use evidence to solve these problems. We also explored (3) the measured and (4) perceived effects of the evidence-based leadership approach in healthcare settings. Both qualitative and quantitative components of the effects of evidence-based leadership were examined to provide greater insights into the available literature [ 33 ]. Together with the evidence-based leadership approach, and its impact on nursing [ 34 , 35 ], this knowledge gained in this review can be used to inform clinical policy or organizational decisions [ 33 ]. The study is registered (PROSPERO CRD42021259624). The methods used in this review were specified in advance and documented in a priori in a published protocol [ 36 ]. Key terms of the review and the search terms are defined in Table  1 (population, intervention, comparison, outcomes, context, other).

In this review, we used a mixed methods approach [ 37 ]. A mixed methods systematic review was selected as this approach has the potential to produce direct relevance to policy makers and practitioners [ 38 ]. Johnson and Onwuegbuzie [ 39 ] have defined mixed methods research as “the class of research in which the researcher mixes or combines quantitative and qualitative research techniques, methods, approaches, concepts or language into a single study.” Therefore, we combined quantitative and narrative analysis to appraise and synthesize empirical evidence, and we held them as equally important in informing clinical policy or organizational decisions [ 34 ]. In this review, a comprehensive synthesis of quantitative and qualitative data was performed first and then discussed in discussion part (parallel-results convergent design) [ 40 ]. We hoped that different type of analysis approaches could complement each other and deeper picture of the topic in line with our research questions could be gained [ 34 ].

Inclusion and exclusion criteria

Inclusion and exclusion criteria of the study are described in Table  1 .

Search strategy

A three-step search strategy was utilized. First, an initial limited search with #MEDLINE was undertaken, followed by analysis of the words used in the title, abstract, and the article’s key index terms. Second, the search strategy, including identified keywords and index terms, was adapted for each included data base and a second search was undertaken on 11 November 2021. The full search strategy for each database is described in Additional file 1 . Third, the reference list of all studies included in the review were screened for additional studies. No year limits or language restrictions were used.

Information sources

The database search included the following: CINAHL (EBSCO), Cochrane Library (academic database for medicine and health science and nursing), Embase (Elsevier), PsycINFO (EBSCO), PubMed (MEDLINE), Scopus (Elsevier) and Web of Science (academic database across all scientific and technical disciplines, ranging from medicine and social sciences to arts and humanities). These databases were selected as they represent typical databases in health care context. Subject headings from each of the databases were included in the search strategies. Boolean operators ‘AND’ and ‘OR’ were used to combine the search terms. An information specialist from the University of Turku Library was consulted in the formation of the search strategies.

Study selection

All identified citations were collated and uploaded into Covidence software (Covidence systematic review software, Veritas Health Innovation, Melbourne, Australia www.covidence.org ), and duplicates were removed by the software. Titles and abstracts were screened and assessed against the inclusion criteria independently by two reviewers out of four, and any discrepancies were resolved by the third reviewer (MV, KH, TL, WC). Studies meeting the inclusion criteria were retrieved in full and archived in Covidence. Access to one full-text article was lacking: the authors for one study were contacted about the missing full text, but no full text was received. All remaining hits of the included studies were retrieved and assessed independently against the inclusion criteria by two independent reviewers of four (MV, KH, TL, WC). Studies that did not meet the inclusion criteria were excluded, and the reasons for exclusion were recorded in Covidence. Any disagreements that arose between the reviewers were resolved through discussions with XL.

Assessment of methodological quality

Eligible studies were critically appraised by two independent reviewers (YT, SH). Standardized critical appraisal instruments based on the study design were used. First, quasi-experimental studies were assessed using the JBI Critical Appraisal Checklist for Quasi-experimental studies [ 44 ]. Second, case series were assessed using the JBI Critical Appraisal Checklist for Case Series [ 45 ]. Third, mixed methods studies were appraised using the Mixed Methods Appraisal Tool [ 46 ].

To increase inter-reviewer reliability, the review agreement was calculated (SH) [ 47 ]. A kappa greater than 0.8 was considered to represent a high level of agreement (0–0.1). In our data, the agreement was 0.75. Discrepancies raised between two reviewers were resolved through discussion and modifications and confirmed by XL. As an outcome, studies that met the inclusion criteria were proceeded to critical appraisal and assessed as suitable for inclusion in the review. The scores for each item and overall critical appraisal scores were presented.

Data extraction

For data extraction, specific tables were created. First, study characteristics (author(s), year, country, design, number of participants, setting) were extracted by two authors independently (JC, MV) and reviewed by TL. Second, descriptions of the interventions were extracted by two reviewers (JV, JC) using the structure of the TIDIeR (Template for Intervention Description and Replication) checklist (brief name, the goal of the intervention, material and procedure, models of delivery and location, dose, modification, adherence and fidelity) [ 48 ]. The extractions were confirmed (MV).

Third, due to a lack of effectiveness data and a wide heterogeneity between study designs and presentation of outcomes, no attempt was made to pool the quantitative data statistically; the findings of the quantitative data were presented in narrative form only [ 44 ]. The separate data extraction tables for each research question were designed specifically for this study. For both qualitative (and a qualitative component of mixed-method studies) and quantitative studies, the data were extracted and tabulated into text format according to preplanned research questions [ 36 ]. To test the quality of the tables and the data extraction process, three authors independently extracted the data from the first five studies (in alphabetical order). After that, the authors came together to share and determine whether their approaches of the data extraction were consistent with each other’s output and whether the content of each table was in line with research question. No reason was found to modify the data extraction tables or planned process. After a consensus of the data extraction process was reached, the data were extracted in pairs by independent reviewers (WC, TY, SH, GL). Any disagreements that arose between the reviewers were resolved through discussion and with a third reviewer (MV).

Data analysis

We were not able to conduct a meta-analysis due to a lack of effectiveness data based on clinical trials. Instead, we used inductive thematic analysis with constant comparison to answer the research question [ 46 , 49 ] using tabulated primary data from qualitative and quantitative studies as reported by the original authors in narrative form only [ 47 ]. In addition, the qualitizing process was used to transform quantitative data to qualitative data; this helped us to convert the whole data into themes and categories. After that we used the thematic analysis for the narrative data as follows. First, the text was carefully read, line by line, to reveal topics answering each specific review question (MV). Second, the data coding was conducted, and the themes in the data were formed by data categorization. The process of deriving the themes was inductive based on constant comparison [ 49 ]. The results of thematic analysis and data categorization was first described in narrative format and then the total number of studies was calculated where the specific category was identified (%).

Stakeholder involvement

The method of reporting stakeholders’ involvement follows the key components by [ 50 ]: (1) people involved, (2) geographical location, (3) how people were recruited, (4) format of involvement, (5) amount of involvement, (6) ethical approval, (7) financial compensation, and (8) methods for reporting involvement.

In our review, stakeholder involvement targeted nurses and nurse leader in China. Nurse Directors of two hospitals recommended potential participants who received a personal invitation letter from researchers to participate in a discussion meeting. Stakeholders’ participation was based on their own free will. Due to COVID-19, one online meeting (1 h) was organized (25 May 2022). Eleven participants joined the meeting. Ethical approval was not applied and no financial compensation was offered. At the end of the meeting, experiences of stakeholders’ involvement were explored.

The meeting started with an introductory presentation with power points. The rationale, methods, and preliminary review results were shared with the participants [ 51 ].The meeting continued with general questions for the participants: (1) Are you aware of the concepts of evidence-based practice or evidence-based leadership?; (2) How important is it to use evidence to support decisions among nurse leaders?; (3) How is the evidence-based approach used in hospital settings?; and (4) What type of evidence is currently used to support nurse leaders’ decision making (e.g. scientific literature, organizational data, stakeholder views)?

Two people took notes on the course and content of the conversation. The notes were later transcripted in verbatim, and the key points of the discussions were summarised. Although answers offered by the stakeholders were very short, the information was useful to validate the preliminary content of the results, add the rigorousness of the review, and obtain additional perspectives. A recommendation of the stakeholders was combined in the Discussion part of this review increasing the applicability of the review in the real world [ 50 ]. At the end of the discussion, the value of stakeholders’ involvement was asked. Participants shared that the experience of participating was unique and the topic of discussion was challenging. Two authors of the review group further represented stakeholders by working together with the research team throughout the review study.

Search results

From seven different electronic databases, 6053 citations were identified as being potentially relevant to the review. Then, 3133 duplicates were removed by an automation tool (Covidence: www.covidence.org ), and one was removed manually. The titles and abstracts of 3040 of citations were reviewed, and a total of 110 full texts were included (one extra citation was found on the reference list but later excluded). Based on the eligibility criteria, 31 studies (32 hits) were critically appraised and deemed suitable for inclusion in the review. The search results and selection process are presented in the PRISMA [ 52 ] flow diagram Fig.  1 . The full list of references for included studies can be find in Additional file 2 . To avoid confusion between articles of the reference list and studies included in the analysis, the studies included in the review are referred inside the article using the reference number of each study (e.g. ref 1, ref 2).

figure 1

Search results and study selection and inclusion process [ 52 ]

Characteristics of included studies

The studies had multiple purposes, aiming to develop practice, implement a new approach, improve quality, or to develop a model. The 31 studies (across 32 hits) were case series studies ( n  = 27), mixed methods studies ( n  = 3) and a quasi-experimental study ( n  = 1). All studies were published between the years 2004 and 2021. The highest number of papers was published in year 2020.

Table  2 describes the characteristics of included studies and Additional file 3 offers a narrative description of the studies.

Methodological quality assessment

Quasi-experimental studies.

We had one quasi-experimental study (ref 31). All questions in the critical appraisal tool were applicable. The total score of the study was 8 (out of a possible 9). Only one response of the tool was ‘no’ because no control group was used in the study (see Additional file 4 for the critical appraisal of included studies).

Case series studies . A case series study is typically defined as a collection of subjects with common characteristics. The studies do not include a comparison group and are often based on prevalent cases and on a sample of convenience [ 53 ]. Munn et al. [ 45 ] further claim that case series are best described as observational studies, lacking experimental and randomized characteristics, being descriptive studies, without a control or comparator group. Out of 27 case series studies included in our review, the critical appraisal scores varied from 1 to 9. Five references were conference abstracts with empirical study results, which were scored from 1 to 3. Full reports of these studies were searched in electronic databases but not found. Critical appraisal scores for the remaining 22 studies ranged from 1 to 9 out of a possible score of 10. One question (Q3) was not applicable to 13 studies: “Were valid methods used for identification of the condition for all participants included in the case series?” Only two studies had clearly reported the demographic of the participants in the study (Q6). Twenty studies met Criteria 8 (“Were the outcomes or follow-up results of cases clearly reported?”) and 18 studies met Criteria 7 (“Q7: Was there clear reporting of clinical information of the participants?”) (see Additional file 4 for the critical appraisal of included studies).

Mixed-methods studies

Mixed-methods studies involve a combination of qualitative and quantitative methods. This is a common design and includes convergent design, sequential explanatory design, and sequential exploratory design [ 46 ]. There were three mixed-methods studies. The critical appraisal scores for the three studies ranged from 60 to 100% out of a possible 100%. Two studies met all the criteria, while one study fulfilled 60% of the scored criteria due to a lack of information to understand the relevance of the sampling strategy well enough to address the research question (Q4.1) or to determine whether the risk of nonresponse bias was low (Q4.4) (see Additional file 4 for the critical appraisal of included studies).

Intervention or program components

The intervention of program components were categorized and described using the TiDier checklist: name and goal, theory or background, material, procedure, provider, models of delivery, location, dose, modification, and adherence and fidelity [ 48 ]. A description of intervention in each study is described in Additional file 5 and a narrative description in Additional file 6 .

Leadership problems

In line with the inclusion criteria, data for the leadership problems were categorized in all 31 included studies (see Additional file 7 for leadership problems). Three types of leadership problems were identified: implementation of knowledge into practice, the quality of clinical care, and resources in nursing care. A narrative summary of the results is reported below.

Implementing knowledge into practice

Eleven studies (35%) aimed to solve leadership problems related to implementation of knowledge into practice. Studies showed how to support nurses in evidence-based implementation (EBP) (ref 3, ref 5), how to engage nurses in using evidence in practice (ref 4), how to convey the importance of EBP (ref 22) or how to change practice (ref 4). Other problems were how to facilitate nurses to use guideline recommendations (ref 7) and how nurses can make evidence-informed decisions (ref 8). General concerns also included the linkage between theory and practice (ref 1) as well as how to implement the EBP model in practice (ref 6). In addition, studies were motivated by the need for revisions or updates of protocols to improve clinical practice (ref 10) as well as the need to standardize nursing activities (ref 11, ref 14).

The quality of the care

Thirteen (42%) focused on solving problems related to the quality of clinical care. In these studies, a high number of catheter infections led a lack of achievement of organizational goals (ref 2, ref 9). A need to reduce patient symptoms in stem cell transplant patients undergoing high-dose chemotherapy (ref 24) was also one of the problems to be solved. In addition, the projects focused on how to prevent pressure ulcers (ref 26, ref 29), how to enhance the quality of cancer treatment (ref 25) and how to reduce the need for invasive constipation treatment (ref 30). Concerns about patient safety (ref 15), high fall rates (ref 16, ref 19), dissatisfaction of patients (ref 16, ref 18) and nurses (ref 16, ref 30) were also problems that had initiated the projects. Studies addressed concerns about how to promote good contingency care in residential aged care homes (ref 20) and about how to increase recognition of human trafficking problems in healthcare (ref 21).

Resources in nursing care

Nurse leaders identified problems in their resources, especially in staffing problems. These problems were identified in seven studies (23%), which involved concerns about how to prevent nurses from leaving the job (ref 31), how to ensure appropriate recruitment, staffing and retaining of nurses (ref 13) and how to decrease nurses’ burden and time spent on nursing activities (ref 12). Leadership turnover was also reported as a source of dissatisfaction (ref 17); studies addressed a lack of structured transition and training programs, which led to turnover (ref 23), as well as how to improve intershift handoff among nurses (ref 28). Optimal design for new hospitals was also examined (ref 27).

Main features of evidence-based leadership

Out of 31 studies, 17 (55%) included all four domains of an evidence-based leadership approach, and four studies (13%) included evidence of critical appraisal of the results (see Additional file 8 for the main features of evidence-based Leadership) (ref 11, ref 14, ref 23, ref 27).

Organizational evidence

Twenty-seven studies (87%) reported how organizational evidence was collected and used to solve leadership problems (ref 2). Retrospective chart reviews (ref 5), a review of the extent of specific incidents (ref 19), and chart auditing (ref 7, ref 25) were conducted. A gap between guideline recommendations and actual care was identified using organizational data (ref 7) while the percentage of nurses’ working time spent on patient care was analyzed using an electronic charting system (ref 12). Internal data (ref 22), institutional data, and programming metrics were also analyzed to understand the development of the nurse workforce (ref 13).

Surveys (ref 3, ref 25), interviews (ref 3, ref 25) and group reviews (ref 18) were used to better understand the leadership problem to be solved. Employee opinion surveys on leadership (ref 17), a nurse satisfaction survey (ref 30) and a variety of reporting templates were used for the data collection (ref 28) reported. Sometimes, leadership problems were identified by evidence facilitators or a PI’s team who worked with staff members (ref 15, ref 17). Problems in clinical practice were also identified by the Nursing Professional Council (ref 14), managers (ref 26) or nurses themselves (ref 24). Current practices were reviewed (ref 29) and a gap analysis was conducted (ref 4, ref 16, ref 23) together with SWOT analysis (ref 16). In addition, hospital mission and vision statements, research culture established and the proportion of nursing alumni with formal EBP training were analyzed (ref 5). On the other hand, it was stated that no systematic hospital-specific sources of data regarding job satisfaction or organizational commitment were used (ref 31). In addition, statements of organizational analysis were used on a general level only (ref 1).

Scientific evidence identified

Twenty-six studies (84%) reported the use of scientific evidence in their evidence-based leadership processes. A literature search was conducted (ref 21) and questions, PICO, and keywords were identified (ref 4) in collaboration with a librarian. Electronic databases, including PubMed (ref 14, ref 31), Cochrane, and EMBASE (ref 31) were searched. Galiano (ref 6) used Wiley Online Library, Elsevier, CINAHL, Health Source: Nursing/Academic Edition, PubMed, and the Cochrane Library while Hoke (ref 11) conducted an electronic search using CINAHL and PubMed to retrieve articles.

Identified journals were reviewed manually (ref 31). The findings were summarized using ‘elevator speech’ (ref 4). In a study by Gifford et al. (ref 9) evidence facilitators worked with participants to access, appraise, and adapt the research evidence to the organizational context. Ostaszkiewicz (ref 20) conducted a scoping review of literature and identified and reviewed frameworks and policy documents about the topic and the quality standards. Further, a team of nursing administrators, directors, staff nurses, and a patient representative reviewed the literature and made recommendations for practice changes.

Clinical practice guidelines were also used to offer scientific evidence (ref 7, ref 19). Evidence was further retrieved from a combination of nursing policies, guidelines, journal articles, and textbooks (ref 12) as well as from published guidelines and literature (ref 13). Internal evidence, professional practice knowledge, relevant theories and models were synthesized (ref 24) while other study (ref 25) reviewed individual studies, synthesized with systematic reviews or clinical practice guidelines. The team reviewed the research evidence (ref 3, ref 15) or conducted a literature review (ref 22, ref 28, ref 29), a literature search (ref 27), a systematic review (ref 23), a review of the literature (ref 30) or ‘the scholarly literature was reviewed’ (ref 18). In addition, ‘an extensive literature review of evidence-based best practices was carried out’ (ref 10). However, detailed description how the review was conducted was lacking.

Views of stakeholders

A total of 24 studies (77%) reported methods for how the views of stakeholders, i.e., professionals or experts, were considered. Support to run this study was received from nursing leadership and multidisciplinary teams (ref 29). Experts and stakeholders joined the study team in some cases (ref 25, ref 30), and in other studies, their opinions were sought to facilitate project success (ref 3). Sometimes a steering committee was formed by a Chief Nursing Officer and Clinical Practice Specialists (ref 2). More specifically, stakeholders’ views were considered using interviews, workshops and follow-up teleconferences (ref 7). The literature review was discussed with colleagues (ref 11), and feedback and support from physicians as well as the consensus of staff were sought (ref 16).

A summary of the project findings and suggestions for the studies were discussed at 90-minute weekly meetings by 11 charge nurses. Nurse executive directors were consulted over a 10-week period (ref 31). An implementation team (nurse, dietician, physiotherapist, occupational therapist) was formed to support the implementation of evidence-based prevention measures (ref 26). Stakeholders volunteered to join in the pilot implementation (ref 28) or a stakeholder team met to determine the best strategy for change management, shortcomings in evidence-based criteria were discussed, and strategies to address those areas were planned (ref 5). Nursing leaders, staff members (ref 22), ‘process owners (ref 18) and program team members (ref 18, ref 19, ref 24) met regularly to discuss the problems. Critical input was sought from clinical educators, physicians, nutritionists, pharmacists, and nurse managers (ref 24). The unit director and senior nursing staff reviewed the contents of the product, and the final version of clinical pathways were reviewed and approved by the Quality Control Commission of the Nursing Department (ref 12). In addition, two co-design workshops with 18 residential aged care stakeholders were organized to explore their perspectives about factors to include in a model prototype (ref 20). Further, an agreement of stakeholders in implementing continuous quality services within an open relationship was conducted (ref 1).

Critical appraisal

In five studies (16%), a critical appraisal targeting the literature search was carried out. The appraisals were conducted by interns and teams who critiqued the evidence (ref 4). In Hoke’s study, four areas that had emerged in the literature were critically reviewed (ref 11). Other methods were to ‘critically appraise the search results’ (ref 14). Journal club team meetings (ref 23) were organized to grade the level and quality of evidence and the team ‘critically appraised relevant evidence’ (ref 27). On the other hand, the studies lacked details of how the appraisals were done in each study.

The perceived effects of evidence-based leadership

Perceived effects of evidence-based leadership on nurses’ performance.

Eleven studies (35%) described perceived effects of evidence-based leadership on nurses’ performance (see Additional file 9 for perceived effects of evidence-based leadership), which were categorized in four groups: awareness and knowledge, competence, ability to understand patients’ needs, and engagement. First, regarding ‘awareness and knowledge’, different projects provided nurses with new learning opportunities (ref 3). Staff’s knowledge (ref 20, ref 28), skills, and education levels improved (ref 20), as did nurses’ knowledge comprehension (ref 21). Second, interventions and approaches focusing on management and leadership positively influenced participants’ competence level to improve the quality of services. Their confidence level (ref 1) and motivation to change practice increased, self-esteem improved, and they were more positive and enthusiastic in their work (ref 22). Third, some nurses were relieved that they had learned to better handle patients’ needs (ref 25). For example, a systematic work approach increased nurses’ awareness of the patients who were at risk of developing health problems (ref 26). And last, nurse leaders were more engaged with staff, encouraging them to adopt the new practices and recognizing their efforts to change (ref 8).

Perceived effects on organizational outcomes

Nine studies (29%) described the perceived effects of evidence-based leadership on organizational outcomes (see Additional file 9 for perceived effects of evidence-based leadership). These were categorized into three groups: use of resources, staff commitment, and team effort. First, more appropriate use of resources was reported (ref 15, ref 20), and working time was more efficiently used (ref 16). In generally, a structured approach made implementing change more manageable (ref 1). On the other hand, in the beginning of the change process, the feedback from nurses was unfavorable, and they experienced discomfort in the new work style (ref 29). New approaches were also perceived as time consuming (ref 3). Second, nurse leaders believed that fewer nursing staff than expected left the organization over the course of the study (ref 31). Third, the project helped staff in their efforts to make changes, and it validated the importance of working as a team (ref 7). Collaboration and support between the nurses increased (ref 26). On the other hand, new work style caused challenges in teamwork (ref 3).

Perceived effects on clinical outcomes

Five studies (16%) reported the perceived effects of evidence-based leadership on clinical outcomes (see Additional file 9 for perceived effects of evidence-based leadership), which were categorized in two groups: general patient outcomes and specific clinical outcomes. First, in general, the project assisted in connecting the guideline recommendations and patient outcomes (ref 7). The project was good for the patients in general, and especially to improve patient safety (ref 16). On the other hand, some nurses thought that the new working style did not work at all for patients (ref 28). Second, the new approach used assisted in optimizing patients’ clinical problems and person-centered care (ref 20). Bowel management, for example, received very good feedback (ref 30).

The measured effects of evidence-based leadership

The measured effects on nurses’ performance.

Data were obtained from 20 studies (65%) (see Additional file 10 for measured effects of evidence-based leadership) and categorized nurse performance outcomes for three groups: awareness and knowledge, engagement, and satisfaction. First, six studies (19%) measured the awareness and knowledge levels of participants. Internship for staff nurses was beneficial to help participants to understand the process for using evidence-based practice and to grow professionally, to stimulate for innovative thinking, to give knowledge needed to use evidence-based practice to answer clinical questions, and to make possible to complete an evidence-based practice project (ref 3). Regarding implementation program of evidence-based practice, those with formal EBP training showed an improvement in knowledge, attitude, confidence, awareness and application after intervention (ref 3, ref 11, ref 20, ref 23, ref 25). On the contrary, in other study, attitude towards EBP remained stable ( p  = 0.543). and those who applied EBP decreased although no significant differences over the years ( p  = 0.879) (ref 6).

Second, 10 studies (35%) described nurses’ engagement to new practices (ref 5, ref 6, ref 7, ref 10, ref 16, ref 17, ref 18, ref 21, ref 25, ref 27). 9 studies (29%) studies reported that there was an improvement of compliance level of participants (ref 6, ref 7, ref 10, ref 16, ref 17, ref 18, ref 21, ref 25, ref 27). On the contrary, in DeLeskey’s (ref 5) study, although improvement was found in post-operative nausea and vomiting’s (PONV) risk factors documented’ (2.5–63%), and ’risk factors communicated among anaesthesia and surgical staff’ (0–62%), the improvement did not achieve the goal. The reason was a limited improvement was analysed. It was noted that only those patients who had been seen by the pre-admission testing nurse had risk assessments completed. Appropriate treatment/prophylaxis increased from 69 to 77%, and from 30 to 49%; routine assessment for PONV/rescue treatment 97% and 100% was both at 100% following the project. The results were discussed with staff but further reasons for a lack of engagement in nursing care was not reported.

And third, six studies (19%) reported nurses’ satisfaction with project outcomes. The study results showed that using evidence in managerial decisions improved nurses’ satisfaction and attitudes toward their organization ( P  < 0.05) (ref 31). Nurses’ overall job satisfaction improved as well (ref 17). Nurses’ satisfaction with usability of the electronic charting system significantly improved after introduction of the intervention (ref 12). In handoff project in seven hospitals, improvement was reported in all satisfaction indicators used in the study although improvement level varied in different units (ref 28). In addition, positive changes were reported in nurses’ ability to autonomously perform their job (“How satisfied are you with the tools and resources available for you treat and prevent patient constipation?” (54%, n  = 17 vs. 92%, n  = 35, p  < 0.001) (ref 30).

The measured effects on organizational outcomes

Thirteen studies (42%) described the effects of a project on organizational outcomes (see Additional file 10 for measured effects of evidence-based leadership), which were categorized in two groups: staff compliance, and changes in practices. First, studies reported improved organizational outcomes due to staff better compliance in care (ref 4, ref 13, ref 17, ref 23, ref 27, ref 31). Second, changes in organization practices were also described (ref 11) like changes in patient documentation (ref 12, ref 21). Van Orne (ref 30) found a statistically significant reduction in the average rate of invasive medication administration between pre-intervention and post-intervention ( p  = 0.01). Salvador (ref 24) also reported an improvement in a proactive approach to mucositis prevention with an evidence-based oral care guide. On the contrary, concerns were also raised such as not enough time for new bedside report (ref 16) or a lack of improvement of assessment of diabetic ulcer (ref 8).

The measured effects on clinical outcomes

A variety of improvements in clinical outcomes were reported (see Additional file 10 for measured effects of evidence-based leadership): improvement in patient clinical status and satisfaction level. First, a variety of improvement in patient clinical status was reported. improvement in Incidence of CAUTI decreased 27.8% between 2015 and 2019 (ref 2) while a patient-centered quality improvement project reduced CAUTI rates to 0 (ref 10). A significant decrease in transmission rate of MRSA transmission was also reported (ref 27) and in other study incidences of CLABSIs dropped following of CHG bathing (ref 14). Further, it was possible to decrease patient nausea from 18 to 5% and vomiting to 0% (ref 5) while the percentage of patients who left the hospital without being seen was below 2% after the project (ref 17). In addition, a significant reduction in the prevalence of pressure ulcers was found (ref 26, ref 29) and a significant reduction of mucositis severity/distress was achieved (ref 24). Patient falls rate decreased (ref 15, ref 16, ref 19, ref 27).

Second, patient satisfaction level after project implementation improved (ref 28). The scale assessing healthcare providers by consumers showed improvement, but the changes were not statistically significant. Improvement in an emergency department leadership model and in methods of communication with patients improved patient satisfaction scores by 600% (ref 17). In addition, new evidence-based unit improved patient experiences about the unit although not all items improved significantly (ref 18).

Stakeholder involvement in the mixed-method review

To ensure stakeholders’ involvement in the review, the real-world relevance of our research [ 53 ], achieve a higher level of meaning in our review results, and gain new perspectives on our preliminary findings [ 50 ], a meeting with 11 stakeholders was organized. First, we asked if participants were aware of the concepts of evidence-based practice or evidence-based leadership. Responses revealed that participants were familiar with the concept of evidence-based practice, but the topic of evidence-based leadership was totally new. Examples of nurses and nurse leaders’ responses are as follows: “I have heard a concept of evidence-based practice but never a concept of evidence-based leadership.” Another participant described: “I have heard it [evidence-based leadership] but I do not understand what it means.”

Second, as stakeholder involvement is beneficial to the relevance and impact of health research [ 54 ], we asked how important evidence is to them in supporting decisions in health care services. One participant described as follows: “Using evidence in decisions is crucial to the wards and also to the entire hospital.” Third, we asked how the evidence-based approach is used in hospital settings. Participants expressed that literature is commonly used to solve clinical problems in patient care but not to solve leadership problems. “In [patient] medication and care, clinical guidelines are regularly used. However, I am aware only a few cases where evidence has been sought to solve leadership problems.”

And last, we asked what type of evidence is currently used to support nurse leaders’ decision making (e.g. scientific literature, organizational data, stakeholder views)? The participants were aware that different types of information were collected in their organization on a daily basis (e.g. patient satisfaction surveys). However, the information was seldom used to support decision making because nurse leaders did not know how to access this information. Even so, the participants agreed that the use of evidence from different sources was important in approaching any leadership or managerial problems in the organization. Participants also suggested that all nurse leaders should receive systematic training related to the topic; this could support the daily use of the evidence-based approach.

To our knowledge, this article represents the first mixed-methods systematic review to examine leadership problems, how evidence is used to solve these problems and what the perceived and measured effects of evidence-based leadership are on nurse leaders and their performance, organizational, and clinical outcomes. This review has two key findings. First, the available research data suggests that evidence-based leadership has potential in the healthcare context, not only to improve knowledge and skills among nurses, but also to improve organizational outcomes and the quality of patient care. Second, remarkably little published research was found to explore the effects of evidence-based leadership with an efficient trial design. We validated the preliminary results with nurse stakeholders, and confirmed that nursing staff, especially nurse leaders, were not familiar with the concept of evidence-based leadership, nor were they used to implementing evidence into their leadership decisions. Our data was based on many databases, and we screened a large number of studies. We also checked existing registers and databases and found no registered or ongoing similar reviews being conducted. Therefore, our results may not change in the near future.

We found that after identifying the leadership problems, 26 (84%) studies out of 31 used organizational data, 25 (81%) studies used scientific evidence from the literature, and 21 (68%) studies considered the views of stakeholders in attempting to understand specific leadership problems more deeply. However, only four studies critically appraised any of these findings. Considering previous critical statements of nurse leaders’ use of evidence in their decision making [ 14 , 30 , 31 , 34 , 55 ], our results are still quite promising.

Our results support a previous systematic review by Geert et al. [ 32 ], which concluded that it is possible to improve leaders’ individual-level outcomes, such as knowledge, motivation, skills, and behavior change using evidence-based approaches. Collins and Holton [ 23 ] particularly found that leadership training resulted in significant knowledge and skill improvements, although the effects varied widely across studies. In our study, evidence-based leadership was seen to enable changes in clinical practice, especially in patient care. On the other hand, we understand that not all efforts to changes were successful [ 56 , 57 , 58 ]. An evidence-based approach causes negative attitudes and feelings. Negative emotions in participants have also been reported due to changes, such as discomfort with a new working style [ 59 ]. Another study reported inconvenience in using a new intervention and its potential risks for patient confidentiality. Sometimes making changes is more time consuming than continuing with current practice [ 60 ]. These findings may partially explain why new interventions or program do not always fully achieve their goals. On the other hand, Dubose et al. [ 61 ] state that, if prepared with knowledge of resistance, nurse leaders could minimize the potential negative consequences and capitalize on a powerful impact of change adaptation.

We found that only six studies used a specific model or theory to understand the mechanism of change that could guide leadership practices. Participants’ reactions to new approaches may be an important factor in predicting how a new intervention will be implemented into clinical practice. Therefore, stronger effort should be put to better understanding the use of evidence, how participants’ reactions and emotions or practice changes could be predicted or supported using appropriate models or theories, and how using these models are linked with leadership outcomes. In this task, nurse leaders have an important role. At the same time, more responsibilities in developing health services have been put on the shoulders of nurse leaders who may already be suffering under pressure and increased burden at work. Working in a leadership position may also lead to role conflict. A study by Lalleman et al. [ 62 ] found that nurses were used to helping other people, often in ad hoc situations. The helping attitude of nurses combined with structured managerial role may cause dilemmas, which may lead to stress. Many nurse leaders opt to leave their positions less than 5 years [ 63 ].To better fulfill the requirements of health services in the future, the role of nurse leaders in evidence-based leadership needs to be developed further to avoid ethical and practical dilemmas in their leadership practices.

It is worth noting that the perceived and measured effects did not offer strong support to each other but rather opened a new venue to understand the evidence-based leadership. Specifically, the perceived effects did not support to measured effects (competence, ability to understand patients’ needs, use of resources, team effort, and specific clinical outcomes) while the measured effects could not support to perceived effects (nurse’s performance satisfaction, changes in practices, and clinical outcomes satisfaction). These findings may indicate that different outcomes appear if the effects of evidence-based leadership are looked at using different methodological approach. Future study is encouraged using well-designed study method including mixed-method study to examine the consistency between perceived and measured effects of evidence-based leadership in health care.

There is a potential in nursing to support change by demonstrating conceptual and operational commitment to research-based practices [ 64 ]. Nurse leaders are well positioned to influence and lead professional governance, quality improvement, service transformation, change and shared governance [ 65 ]. In this task, evidence-based leadership could be a key in solving deficiencies in the quality, safety of care [ 14 ] and inefficiencies in healthcare delivery [ 12 , 13 ]. As WHO has revealed, there are about 28 million nurses worldwide, and the demand of nurses will put nurse resources into the specific spotlight [ 1 ]. Indeed, evidence could be used to find solutions for how to solve economic deficits or other problems using leadership skills. This is important as, when nurses are able to show leadership and control in their own work, they are less likely to leave their jobs [ 66 ]. On the other hand, based on our discussions with stakeholders, nurse leaders are not used to using evidence in their own work. Further, evidence-based leadership is not possible if nurse leaders do not have access to a relevant, robust body of evidence, adequate funding, resources, and organizational support, and evidence-informed decision making may only offer short-term solutions [ 55 ]. We still believe that implementing evidence-based strategies into the work of nurse leaders may create opportunities to protect this critical workforce from burnout or leaving the field [ 67 ]. However, the role of the evidence-based approach for nurse leaders in solving these problems is still a key question.

Limitations

This study aimed to use a broad search strategy to ensure a comprehensive review but, nevertheless, limitations exist: we may have missed studies not included in the major international databases. To keep search results manageable, we did not use specific databases to systematically search grey literature although it is a rich source of evidence used in systematic reviews and meta-analysis [ 68 ]. We still included published conference abstract/proceedings, which appeared in our scientific databases. It has been stated that conference abstracts and proceedings with empirical study results make up a great part of studies cited in systematic reviews [ 69 ]. At the same time, a limited space reserved for published conference publications can lead to methodological issues reducing the validity of the review results [ 68 ]. We also found that the great number of studies were carried out in western countries, restricting the generalizability of the results outside of English language countries. The study interventions and outcomes were too different across studies to be meaningfully pooled using statistical methods. Thus, our narrative synthesis could hypothetically be biased. To increase transparency of the data and all decisions made, the data, its categorization and conclusions are based on original studies and presented in separate tables and can be found in Additional files. Regarding a methodological approach [ 34 ], we used a mixed methods systematic review, with the core intention of combining quantitative and qualitative data from primary studies. The aim was to create a breadth and depth of understanding that could confirm to or dispute evidence and ultimately answer the review question posed [ 34 , 70 ]. Although the method is gaining traction due to its usefulness and practicality, guidance in combining quantitative and qualitative data in mixed methods systematic reviews is still limited at the theoretical stage [ 40 ]. As an outcome, it could be argued that other methodologies, for example, an integrative review, could have been used in our review to combine diverse methodologies [ 71 ]. We still believe that the results of this mixed method review may have an added value when compared with previous systematic reviews concerning leadership and an evidence-based approach.

Our mixed methods review fills the gap regarding how nurse leaders themselves use evidence to guide their leadership role and what the measured and perceived impact of evidence-based leadership is in nursing. Although the scarcity of controlled studies on this topic is concerning, the available research data suggest that evidence-based leadership intervention can improve nurse performance, organizational outcomes, and patient outcomes. Leadership problems are also well recognized in healthcare settings. More knowledge and a deeper understanding of the role of nurse leaders, and how they can use evidence in their own managerial leadership decisions, is still needed. Despite the limited number of studies, we assume that this narrative synthesis can provide a good foundation for how to develop evidence-based leadership in the future.

Implications

Based on our review results, several implications can be recommended. First, the future of nursing success depends on knowledgeable, capable, and strong leaders. Therefore, nurse leaders worldwide need to be educated about the best ways to manage challenging situations in healthcare contexts using an evidence-based approach in their decisions. This recommendation was also proposed by nurses and nurse leaders during our discussion meeting with stakeholders.

Second, curriculums in educational organizations and on-the-job training for nurse leaders should be updated to support general understanding how to use evidence in leadership decisions. And third, patients and family members should be more involved in the evidence-based approach. It is therefore important that nurse leaders learn how patients’ and family members’ views as stakeholders are better considered as part of the evidence-based leadership approach.

Future studies should be prioritized as follows: establishment of clear parameters for what constitutes and measures evidence-based leadership; use of theories or models in research to inform mechanisms how to effectively change the practice; conducting robust effectiveness studies using trial designs to evaluate the impact of evidence-based leadership; studying the role of patient and family members in improving the quality of clinical care; and investigating the financial impact of the use of evidence-based leadership approach within respective healthcare systems.

Data availability

The authors obtained all data for this review from published manuscripts.

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Acknowledgements

We want to thank the funding bodies, the Finnish National Agency of Education, Asia Programme, the Department of Nursing Science at the University of Turku, and Xiangya School of Nursing at the Central South University. We also would like to thank the nurses and nurse leaders for their valuable opinions on the topic.

The work was supported by the Finnish National Agency of Education, Asia Programme (grant number 26/270/2020) and the University of Turku (internal fund 26003424). The funders had no role in the study design and will not have any role during its execution, analysis, interpretation of the data, decision to publish, or preparation of the manuscript.

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Maritta Välimäki, Tella Lantta, Kirsi Hipp & Jaakko Varpula

School of Public Health, University of Helsinki, Helsinki, FI-00014, Finland

Maritta Välimäki

Xiangya Nursing, School of Central South University, Changsha, 410013, China

Shuang Hu, Jiarui Chen, Yao Tang, Wenjun Chen & Xianhong Li

School of Health and Social Services, Häme University of Applied Sciences, Hämeenlinna, Finland

Hunan Cancer Hospital, Changsha, 410008, China

Gaoming Liu

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Study design: MV, XL. Literature search and study selection: MV, KH, TL, WC, XL. Quality assessment: YT, SH, XL. Data extraction: JC, MV, JV, WC, YT, SH, GL. Analysis and interpretation: MV, SH. Manuscript writing: MV. Critical revisions for important intellectual content: MV, XL. All authors read and approved the final manuscript.

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Differences between the original protocol

We modified criteria for the included studies: we included published conference abstracts/proceedings, which form a relatively broad knowledge base in scientific knowledge. We originally planned to conduct a survey with open-ended questions followed by a face-to-face meeting to discuss the preliminary results of the review. However, to avoid extra burden in nurses due to COVID-19, we decided to limit the validation process to the online discussion only.

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Välimäki, M., Hu, S., Lantta, T. et al. The impact of evidence-based nursing leadership in healthcare settings: a mixed methods systematic review. BMC Nurs 23 , 452 (2024). https://doi.org/10.1186/s12912-024-02096-4

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Trends of Nursing Research on Accidental Falls: A Topic Modeling Analysis

Associated data.

No new data were created or analyzed in this study. Data sharing is not applicable to this article.

This descriptive study analyzed 1849 international and 212 Korean studies to explore the main topics of nursing research on accidental falls. We extracted only nouns from each abstract, and four topics were identified through topic modeling, which were divided into aspects of fall prevention and its consequences. “Fall prevention program and scale” is popular among studies on the validity of fall risk assessment tools and the development of exercise and education programs. “Nursing strategy for fall prevention” is common in studies on nurse education programs and practice guidelines to improve the quality of patient safety care. “Hospitalization by fall injury” is used in studies about delayed discharge, increased costs, and deaths of subjects with fall risk factors hospitalized at medical institutions due to fall-related injuries. “Long-term care facility falls” is popular in studies about interventions to prevent fall injuries that occur in conjunction with dementia in long-term care facilities. It is necessary to establish a system and policy for fall prevention in Korean medical institutions. This study confirms the trends in domestic and international fall-related research, suggesting the need for studies to address insufficient fall-related policies and systems and translational research to be applied in clinical trials.

1. Introduction

Falls refer to unintentional changes in posture toward the floor or a lower position [ 1 ]. Falls represent a crucial patient safety issue in healthcare facilities worldwide and are often used as an index to evaluate the quality of nursing [ 2 , 3 ]. The incidence of patient falls varies among countries and medical institutions. In the United States, 3.3–11.5 falls are observed per 1000 hospitalization days, while in South Korea 400–700 falls annually have been reported [ 4 , 5 , 6 , 7 , 8 , 9 ]. Falls often have negative consequences, including physical injuries such as bleeding and fractures, psychological damage such as anxiety, fear, and loss of independence, and even death [ 10 , 11 , 12 ]. Furthermore, fall-related injuries increase socioeconomic burdens because of increased hospital stays and medical expenses [ 13 , 14 ]. Moreover, in attempts to prevent falls due to these socioeconomic issues, fall-related nursing research has been extensively carried out to date. This study details the current status of fall-related nursing research and its trends over time.

Various measures have been implemented on an international level to prevent falls in care facilities. In 2005, the Joint Commission International (JCI) listed falls as an essential standard item of international patient safety targets [ 15 , 16 ]. In 2008, the Centers for Medicare and Medicaid Services designated falls as a preventable injury, which further increased caution and interest in fall prevention [ 17 ]. In South Korea, falls have been listed as a mandatory item in the certification guidelines of the Korea Institute for Healthcare & Accreditation to reduce fall-related injuries [ 18 , 19 ]. Additionally, in 2013 and 2016, respectively, comprehensive nursing service laws and patient safety laws were enforced to prevent and manage falls [ 20 , 21 ].

Various nursing-related studies have also been conducted in and outside South Korea to develop nursing intervention plans to prevent falls. In particular, systematic literature reviews and meta-analyses have been conducted on previously published fall-related nursing studies, as well as various other studies on the definition [ 22 ], incidence [ 23 ], and risk factors of falls [ 24 , 25 , 26 ], fall risk assessment tools [ 27 , 28 ], and the effects of fall prevention programs [ 29 , 30 , 31 , 32 ]. However, the focus of many systematic literature review studies has been limited to specific areas such as the subjects, variables, environments, and interventions of studies. Thus, many studies could not be included, which limited the derivation of integrated results [ 33 ]. Further, since falls are caused by a combination of intrinsic and extrinsic factors [ 1 , 34 ], an integrated body of knowledge—such as interrelationships of issues and changes and trends over time—needs to be utilized in clinical practice [ 6 ].

Nurses are the key professionals responsible for fall prevention education and management for patient safety in hospitals and communities [ 35 , 36 ]. Further, the JCI emphasizes the importance of nursing in fall prevention by providing periodic fall risk assessments by nurses and additional nursing interventions [ 14 ]. Considering the increasing expectations from nurses to prevent falls, it would be purposeful to suggest the direction of future nursing studies for the development of effective fall prevention nursing interventions. This can be accomplished by evaluating the trends and courses of fall-related nursing studies conducted thus far, both in South Korea and internationally.

Recently, futurological studies using topic modeling as a big data analysis method to track changes in issues over time and predict future issues have gained interest [ 37 , 38 ]. Existing studies have also attempted to analyze research trends, such as the current status of studies and trends over time [ 39 , 40 ]. Analyses of abstracts and keywords have also been performed to examine research trends [ 41 ]. Topic modeling provides integrated information by identifying potential topics in the texts and analyzing the relationships between topics and their distribution [ 42 ]; this helps to microscopically identify key themes and relationships and macroscopically understand the flow and context of the main topics and the trend of topics by period [ 43 , 44 ]. Therefore, topic modeling is a valuable methodology for forming a body of knowledge on nursing studies that can be used to assess the pattern of texts and contextual structures through quantitative and qualitative analysis [ 45 , 46 ]. A fall is a sudden complex event that occurs by combining intrinsic and extrinsic factors and affects many aspects of individuals, society, and local communities [ 1 , 34 ]. It will be effective to analyze the flow and trends of big data of fall-related nursing research over time using topic modeling. Considering that studies related to social interest in falls will continue to increase in the future [ 47 , 48 , 49 ], delineating trends in fall-related nursing research to the present and directions of future research have significance not only for nursing studies but also for nursing practice.

This study explored the trends and patterns of fall-related nursing research by identifying the main topics of fall-related nursing research and changes over time. We used topic modeling to establish a nursing studies body of knowledge and present basic data for the development of fall-related nursing studies in the future. In particular, applying topic modeling in this study, which is the latest analysis technique in nursing [ 50 ], enabled a comprehensive understanding of current fall-related nursing research and core keywords as well as trends in research topics related to falls. These data may contribute to suggesting future directions for nursing research.

2. Materials and Methods

2.1. study design.

This was a descriptive survey study that assessed the topics and trends of each main topic in fall-related nursing studies over time using topic modeling.

2.2. Subject Studies

Nursing studies related to patient falls were selected by searching international academic databases, including MEDLINE (PubMed), EMBASE (Excerpta Medica Database; Elsevier), Cochrane, CINAHL (Cumulative Index to Nursing and Allied Health Literature; EBSCO), Scopus, and Web of Science. Korean databases such as Research Information Sharing Service (RISS), National Digital Science Library (NDSL), and Korean Studies Information Service System (KISS) were searched for domestic studies. Relevant studies up to May 2020 were included. Studies that were published internationally (countries excluding South Korea) from 1974 and South Korean studies published from 1998 were included in this study. Those that were not journal articles (i.e., letters to editors, conference proceedings, and books) and whose abstracts were not available or written in languages other than English were excluded. In particular, non-fall-related international studies where the word “fall” was used in other contexts (i.e., fall asleep, fall in love, fall short, and sliding-scale insulin) were excluded.

2.3. Data Collection

English keywords were used in the searches, including “Accidental Falls”, “Fall”, “Falling”, “Slip*”, and “Slid*”, which were established by mixing natural language and medical subject heading (MeSH) terms; further, “And nurses*” was added to limit the search to fall-related nursing studies. The search content, document type, and language were limited to titles, articles, and English, respectively. Korean databases were searched using various combinations of “fall, nursing”, and “fall nursing”, and a literature search was performed with the advice of a nursing subject specialist librarian. The inclusion criteria were papers registered in domestic and international academic journals that reported nursing research related to falls. Exclusion criteria were papers with no abstracts and papers whose abstracts were not in Korean or English. Among the 6301 papers searched in international databases, 2450 papers were excluded and 3851 papers were reviewed based on their title and abstract. We then excluded 1274 papers not related to falls, 722 papers that were not articles, and 6 papers whose abstracts were not provided. Of the 570 papers searched in Korean databases, 309 papers were excluded and 261 papers were reviewed based on their title and abstract. We then excluded 28 not related to falls, 17 that were not journal articles, and 4 whose abstracts were not provided. The selection of articles was performed by a single researcher and a nursing professor who independently reviewed the titles and abstracts of the articles to exclude those not related to falls. A total of 2061 fall-related nursing studies, with 1849 international and 212 domestic studies, were included in the analysis of this study. The research procedure and flow of this study are shown in Figure 1 .

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Research flow.

2.4. Data Analysis

To prevent multiple selections of the same articles, bibliographic information—including authors’ names, publication year, title, and abstract—was exported to an Excel spreadsheet using EndNote X9 software. The abstract is the most likely section to contain keywords, other than the full text; therefore, the abstracts of the articles were analyzed according to a previous study [ 41 ]. Additionally, only nouns were extracted, according to a previous study, to facilitate the understanding of key concepts [ 51 ].

When texts are analyzed, it is necessary to refine the words as uppercase and lowercase letters, singular and plural, abbreviations, and special characters; in English, these differences can cause keywords to be classified as different words. Thus, dictionaries of designated keywords, synonyms, and excluded words were created to refine the words used for the analysis [ 52 ]. The dictionary of designated words allowed us to extract words in cases of multiple words having a single meaning [ 30 , 51 ]. Additionally, words that should be designated as proper or compound nouns such as “body mass index”, “Braden scale”, “pressure ulcer”, and “cardiovascular diseases” were organized in a dictionary. The dictionary of synonyms collated different words with the same or similar meanings and selected one representative word [ 30 , 53 ]; representative words of the MeSH terms were also organized in a dictionary by grouping words with similar meanings. For example, “Nurses”, which is one of the MeSH terms used in this study, was selected as the representative word for synonyms such as “nurse”, “nurses”, “Nurse”, “Nurses”, “registered nurse”, “registered nurses”, and “Registered Nurses”. The dictionary of excluded words removed one-letter words of which the meaning is difficult to understand and words that represent general concepts [ 30 , 54 ], while words related to research methodology (i.e., “background”, “method”, “result”, “discussion”, “conclusion”, “research”, and “study”) and statistics (i.e., “multiple regression analysis”, “Logistic regression analysis”, “correlation analysis”, and “multiple logistic regression”) were included. Moreover, special symbols and abbreviations were also included in the dictionary of excluded words.

Furthermore, frequency analysis was performed using NetMiner version 4.4 to extract words with a high frequency of appearance and influence from the fall-related nursing research. A total of 4142 words were extracted and refined. In this study, the frequency of a word is the number of its occurrences in the entire document. Core keywords were extracted by analyzing the top 20 words.

Topic modeling is an analysis method that estimates the probability of latent topics appearing in a document based on a document-word matrix [ 55 ]. For our study, a document(abstract)-word matrix was created to apply topic modeling. To perform topic modeling, the number of topics must first be determined to confirm the suitability of the research results and the possibility of interpretation through a Latent Dirichlet Allocation (LDA) algorithm using the NetMiner program version 4.4 [ 56 ]. Therefore, the number of topics was determined as the silhouette coefficient value through K-means clustering. K-means clustering minimizes the sum of squares of errors within a cluster. The number of topics and values of α and β—the LDA parameters—are used to select the number of topics with a silhouette coefficient value close to +1 [ 57 ]. Besides the top 10 words, those with the highest probability of appearance per topic were visualized as a topic–keyword map using a topic–word two-mode network. The topic group name was determined by referring to the top words for each topic.

To assess the changes in topics by period, the study timeline was divided into 10-year periods and the first, second, third, fourth, and fifth periods were 1974–1979, 1980–1989, 1990–1999, 2000–2009, and 2010–2020. IBM SPSS Statistics version 25.0 (SPSS, IBM Corporation) software was used to perform a linear regression analysis to identify topic types by assessing the patterns of increasing and decreasing trends by period. Each period was considered as an independent variable, while the weight of the entire document of each topic was considered as a dependent variable to establish a linear regression model. The independence of the assumption of the linear regression model was evaluated using a residual analysis and Durbin–Watson values [ 58 ]. Durbin–Watson values indicate the independence between the error terms after the regression analysis and range between 0 and 4; a value close to 2 indicates that the residuals are independent of each other and that the assumption of the linear regression model is satisfied [ 59 ].

The results of our linear regression analysis can be classified into four topic types, namely hot, warm, cool, and cold, according to the sign of the regression coefficient and the probability of significance. Topics with a positive coefficient sign and statistical significance, indicated by a significance probability of less than 0.05, were classified as “hot topics” with increasing research interest. Contrastingly, topics with a negative coefficient sign and statistical significance, indicated by a significance probability of less than 0.05, were classified as “cold topics” with research interest on the decline. Moreover, topics without statistical significance, indicated by a significance probability of greater than 0.05, were classified as “warm” and “cool” topics if the coefficient sign was positive or negative, respectively [ 60 , 61 ].

2.5. Ethical Considerations

This study was exempted from approval by the institutional review board of the first author’s affiliate university (IRB No. 1041078-202005-HRSB-132-01).

3.1. Core Keywords

A total of 4142 words were extracted and refined from the abstracts of 2061 papers. The 20 most frequently occurring keywords in fall-related nursing research are shown in Table 1 . The simple frequency of words was as follows: “medication” (1166 times), “fall prevention” (954), “fall injury” (933), “older adult” (802), “educational program” (765), “fracture” (744), “quality” (665), “restraint” (647), “patient safety” (611), and “health” (609).

Core keywords by frequency.

RankKeywordFrequencyRankKeywordFrequency
1medication116611hospitalization549
2fall prevention95412long-term care facility fall525
3fall injury93313dementia506
4older adult80214balance471
5educational program76515physical activity441
6fracture74416fall risk assessment tool386
7quality66517nursing process373
8restraint64718problem364
9patient safety61119fall knowledge363
10health60920adverse effects359

3.2. Topic Modeling

The number of topics for fall-related nursing studies was determined based on the extracted silhouette coefficient, which was calculated using the number of topics and LDA α and β. An upper silhouette coefficient value of 0.939 was calculated with four topics and LDA parameters of α = 0.2 and β = 0.02; thus, four topics were modeled. The keywords of fall-related nursing studies by topic are provided in Table 2 .

Topic group and high-ranking keywords.

CategoryTopic 1Topic 2Topic 3Topic 4
Topic groupfall prevention program and scalenursing strategy for fall preventionhospitalization by fall injurylong-term care facility fall
Proportion20.28%43.72%17.13%18.87%
High-ranking keywordsbalance0.032fall prevention0.023fracture0.050medication0.069
older adult0.028quality0.019fall injury0.040restraint0.040
exercise program0.021patient safety0.019hospitalization0.028dementia0.031
test0.019educational program0.017stroke0.015long-term care facility fall0.019
fall prevention0.019nursing process0.013cost0.014adverse effects0.018
fear of falling0.019fall knowledge0.011treatment0.014association0.014
educational program0.018implementation0.010osteoporosis0.013fall injury0.012
scale0.016health0.010death0.011older adult0.012
physical activity0.016strategy0.009diagnosis0.010problem0.011
activity of daily living0.015improvement0.008discharge0.010symptom0.009

Topic 1 accounted for 20.28% of all articles, and the top 10 keywords—in order of decreasing probability—were “balance”, “older adult”, “exercise program”, “test”, “fall prevention”, “fear of falling”, “educational program”, “scale”, “physical activity”, and “activity of daily living”, with respective probabilities of 0.032, 0.028, 0.021, 0.019, 0.019, 0.019, 0.018, 0.016, 0.016, and 0.015. Topic 1 was named “fall prevention program and scale” and included papers that improved balance by promoting physical activity and activities of daily living in older adults, developed exercise or education programs to decrease the fear of falling, performed tests, and verified the validity of scales used to assess risk factors.

Topic 2 accounted for 43.72% of all the articles, and the top 10 keywords—in order of decreasing probability—were “fall prevention”, “quality”, “patient safety”, “educational program”, “nursing process”, “fall knowledge”, “implementation”, “health”, “strategy”, and “improvement”, with respective probabilities of 0.023, 0.019, 0.019, 0.017, 0.013, 0.011, 0.010, 0.010, 0.009, and 0.008. Topic 2 was named “nursing strategy for fall prevention” and included studies that provided strategies to increase the quality of nursing and the implementation of patient safety measures to improve subjects’ health problems by developing educational programs and fall-related nursing guidelines to develop the knowledge of falls when nursing processes to prevent falls were applied.

Topic 3 accounted for 17.13% of the studies, and the top 10 keywords—in order of decreasing probability—were “fracture”, “fall injury”, “hospitalization”, “stroke”, “cost”, “treatment”, “osteoporosis”, “death”, “diagnosis”, and “discharge”, with respective probabilities of 0.050, 0.040, 0.028, 0.015, 0.014, 0.014, 0.013, 0.011, 0.010, and 0.010. Topic 3 was referred to as “hospitalization by fall injury” and included studies related to treatment duration, delayed discharge, increased cost, and death after diagnosis of fracture due to fall injury and hospitalization in patients with risk factors for falls, such as osteoporosis and stroke.

Topic 4 accounted for 18.87% of the data, and the top 10 keywords—in order of decreasing probability—were “medication”, “restraint”, “dementia”, “long-term care facility fall”, “adverse effects”, “association”, “fall injury”, “older adult”, “problem”, and “symptom”, with respective probabilities of 0.069, 0.040, 0.031, 0.019, 0.018, 0.014, 0.012, 0.012, 0.011, and 0.009. Topic 4 was named “long-term care facility fall” and included studies on the symptoms of dementia in older adults hospitalized in long-term care facilities, long-term care facility falls associated with the adverse effects of medication treatment, and interventions such as medication treatment and restraint to improve health problems and prevent fall injuries.

The results of visualizing the network of ten keywords in the upper probability distribution of the four main topics using the topic–keyword map are shown in Figure 2 . “Educational program” and “fall prevention” were related to Topics 1 and 2 and were included in the keywords, with top 10 probability distributions in both topics. “Older adult” was related to Topics 1 and 4 and was one of the keywords with top 10 probability distributions in both topics. Moreover, “fall injury” was related to Topics 3 and 4 and was one of the keywords with top 10 probability distributions in both topics. A word cloud according to the frequency of words for each topic is shown in Figure 3 . A word cloud, which is an image created using the NetMiner program version 4.4 to convey words that are used most frequently in a work or body of works, for each topic is shown in Figure 3 .

An external file that holds a picture, illustration, etc.
Object name is ijerph-18-03963-g002.jpg

Two-mode analysis of topic–keyword.

An external file that holds a picture, illustration, etc.
Object name is ijerph-18-03963-g003.jpg

Word clouds by topic.

3.3. Topic Trend

A total of 2061 articles were divided into 10-year intervals, and changes in the topics over time were assessed. A total of 6, 24, 204, 654, and 1173 articles were included in Periods 1, 2, 3, 4, and 5, respectively.

The changes in the proportion of fall-related nursing studies by topic over time are shown in Figure 4 . Topic 1 (fall prevention program and scale) accounted for 16.67% of all articles in Period 2 with four articles. In Period 3, the distribution was 7.35% with 16 articles; moreover, increasing trends were shown with 18.81% (123 articles) and 23.53% (276 articles) in Periods 4 and 5, respectively. Topic 2 (nursing strategy for fall prevention) accounted for 66.67% of all articles in Period 1 with four articles. In Period 2, its proportion was 62.50% with 15 articles, with 50.98% (104 articles) in Period 3; this topic showed a decreasing trend with 45.26% (296 articles) and 41.09% (482 articles) in Periods 4 and 5, respectively. Topic 3 (hospitalization by fall injury) accounted for 16.67% of all articles in Period 1 with one article. In Period 2, the proportion decreased to 12.50% with three articles, and in Period 3, it was 20.59% with 42 articles. In Periods 4 and 5, a decreasing trend was observed with 16.97% (111 articles) and 16.71% (196 articles), respectively. Topic 4 (long-term care facility fall) accounted for 16.67% of all articles in Period 1 with one article. In Period 2, a distribution of 8.33% (2 articles) was observed, which increased to 21.08% with 43 articles in Period 3. However, Periods 4 and 5 showed a decreasing trend, with 18.96% (124 articles) and 18.67% (219 articles) in Periods 4 and 5, respectively.

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Topic trend by period.

The trends of fall-related nursing studies by topic are shown in Table 3 . The four main fall-related nursing study topics were classified according to their regression coefficients and the significance probabilities of the linear regression analysis. The Durbin–Watson value of residual analysis was calculated to assess the independence of the linear regression model; this value was close to 2 in all four topics, indicating that the assumption of independence of the linear regression model was satisfied [ 51 ]. Topic 1 (fall prevention program and scale) was classified as a “hot topic”, as it was statistically significant and had a positive regression coefficient (B = 0.511, t = 3.422, p = 0.001). Topic 2 (nursing strategy for fall prevention) was classified as a “cold topic”, as it was statistically significant and had a negative regression coefficient (B = −0.748, t = −3.244, p = 0.002). However, Topic 3 (hospitalization by fall injury) was not statistically significant and had a negative regression coefficient. Therefore, it was classified as a “cool topic” (B = −0.099, t = −0.491, p = 0.626), while Topic 4 was classified as a “hot topic” for having statistical significance and a positive regression coefficient (B = 0.337, t = 2.746, p = 0.009).

Topic type by regression coefficient and significance probability.

CategoryBβt -ValueDurbin–WatsonTopic Type
Topic 1 (Fall prevention program and scale)0.5110.4813.4220.0011.443Hot
Topic 2 (Nursing strategy for fall prevention)−0.748−0.461−3.2440.0022.491Cold
Topic 3 (Hospitalization by fall injury)−0.099−0.078−0.4910.6262.518Cool
Topic 4 (Long-term care facility fall)0.3370.4032.7460.0091.569Hot

4. Discussion

This study analyzed the abstracts of fall-related nursing studies and assessed the core keywords, main topics, and trends, as well as the pattern of each topic over time using topic modeling. As a result of assessing the frequency of keywords in fall-related nursing research, meaningful words among the top 20 were “fracture” and “fall risk assessment tool”.

Fracture is one of the common physical injuries caused by falls [ 62 ] and mainly occurs in elderly people with weakened muscle and body conditions due to decreased bone mass associated with aging [ 63 ]. Falls not only cause socioeconomic burdens, such as physical damage, emotional impact, prolonging of hospital stay, and medical expenses [ 63 , 64 ] but are also decisive factors in osteoporotic fractures. As a strategy for preventing osteoporotic fractures [ 65 ], falls must be addressed as a core goal of nursing research. Fall risk assessment tools have been developed and used in a variety of clinical settings, and accurate prediction of high-risk patients is fundamental in fall prevention activities [ 66 ]. Risk assessment tools must identify fall risk patients and thereby enable systematic management to prevent falls; this is a necessary focus for nursing research.

Topic 1 (fall prevention program and scale) was classified as a hot topic with gradually increasing interest over time; the studies on this topic focus on exercise and education programs as interventions for fall prevention. In 2011, the American Geriatrics Society emphasized the assessment of fall risk factors, multi-faceted interventions, and environment adjustments to prevent falls [ 67 ]. It was observed that multi-faceted programs consisting of exercise therapy and education on exercise, nutrition, and environmental adjustment were effective in preventing falls [ 68 ]. A systematic literature review study also suggested the necessity of studies on complex programs that consider physical factors such as balance improvement and psychological factors including depression and cognitive levels [ 69 ]. Studies on multi-faceted interventions that comprehensively consider physical factors such as improving balance and muscle strength, psychological factors such as cognitive decline and depression, and environmental adjustment would be necessary [ 70 ].

The fall guidelines published by the Registered Nurses’ Association of Ontario (RNAO) highlighted using tools that consider both the subjects and the environment [ 71 ]. A systematic review of international studies also suggested that an assessment tool that considers the age and characteristics of the subjects needs to be developed [ 72 ]. In a study published in South Korea, it was suggested that the Morse fall assessment tool is limited to the assessment of subjects’ physical factors and that a fall risk assessment tool that considers the cognitive levels and individual characteristics of the subjects and is suitable for environmental characteristics needs to be developed [ 73 ]. Studies have shown that fall risk assessment tools do not reflect the characteristics of the group with a high risk of falling and that the scores—which serve as the criteria for the high-risk group—did not predict the actual risk of falling [ 74 ]. Moreover, as studies have identified various risk factors for falls—such as osteoporosis, muscle loss, balance, cognitive decline, and the environment [ 75 , 76 ]—it is thought that these studies are limited in their applicability to clinical settings. Therefore, further studies should be performed to develop fall risk assessment tools suitable for the current healthcare system in South Korea and consider the individual characteristics of subjects. Further, translational studies to apply findings of fall risk factors in clinical settings must be conducted.

Topic 2 (nursing strategy for fall prevention) was a cold topic that showed a gradually decreasing trend over time; however, Topic 2 still accounts for a high distribution of all topics. Various nursing strategies have been developed [ 6 , 77 , 78 , 79 ], and, as falls are caused by a combination of factors, nursing strategies that fit the trend and the current environment need to be developed. Fall prevention nursing guidelines in other countries emphasize the importance of policies and support within hospitals, as well as the association between the systems of different departments. In contrast, fall prevention nursing guidelines in South Korea focus on fall nursing practices for individual patients [ 6 ]. In a study published in South Korea that assessed nurses’ experiences of fall accidents [ 73 ], improvements in environmental factors—such as slippery floors, insufficient lighting, bed height, bed railing, and floor shock absorbers—were suggested to prevent falls and reduce fall-related injuries. Moreover, there is a need for systematic support to protect patients from falls and the recruitment of nursing staff to increase the quality and hours of nursing. The fall practice guidelines of the UK Emergency Care Research Institute also emphasize the importance of establishing fall management teams and policies in medical institutions [ 80 ]. Therefore, research on the development and establishment of systems and policies related to fall prevention and management in medical institutions is necessary for South Korea.

Topic 3 (hospitalization by fall injury) was a cool topic with a gradually decreasing trend over time. It could be that the number of studies on the hospitalization outcomes of fall-related injuries is decreasing because studies have been focusing on fall prevention after the Centers for Medicare and Medicaid Services suggested that falls are preventable [ 17 ]. Fall-related injuries require additional diagnostic tests, surgeries, and treatment and have a high recurrence rate of fractures, leading to long-term hospitalization and high medical costs. Falls, therefore, have a negative effect not only on patients and guardians but also socially and economically on the community [ 81 ]. Existing studies on rehabilitation treatment for fractures caused by falls [ 82 ], community preventive interventions and connections with long-term care [ 83 ], and multi-disciplinary approaches have been performed in other countries. In contrast, the number of studies on systems, such as the integrated association between related community organizations [ 84 ], is decreasing in South Korea [ 85 ]. The fall practice guideline published by the Agency for Healthcare Research and Quality emphasized cooperation between multi-disciplinary teams for the prevention and management of falls [ 86 ]; moreover, Oh reported that rehabilitation treatment after the fracture surgery should aim to promote the early recovery of gait ability and sense of balance and that multi-disciplinary cooperation is necessary to prevent falls [ 87 ]. Therefore, studies on the rehabilitation treatment for fall-related injuries in hospitalized patients, the connection to local communities, and a multi-disciplinary approach are necessary for South Korea. Moreover, studies on falls have been biased toward economic perspectives such as the length of stay, mortality, and medical costs of hospitalized patients in medical institutions [ 88 ]. Thus, falls reflect medical accidents and the strict standards for the quality of patient safety in medical institutions [ 89 , 90 ], and studies on the rights, dignity, and safety of individuals who experience falls should be developed in the future.

Topic 4 (long-term care facility fall) was classified as a hot topic with a gradually increasing trend. As the older population has multiplied, the number of older adults with dementia is also increasing [ 91 ]. Although studies on the relationship between falls and older adults with dementia and cognitive impairment have been performed in other countries [ 92 , 93 ], there is a lack of fall-related studies involving older individuals with dementia in South Korea. Previous studies on falls among older adults with dementia and cognitive impairment have been performed; however, only a limited number of studies have been reported, and most studies were conducted on older adults in local communities [ 63 ]. A literature review on interventions for fall prevention in older adults with dementia reported that the individual risk factors of falls need to be assessed to prevent falls [ 94 ], with an interest in the therapeutic and adverse effects of medications that older adults with dementia are consuming, and that assistive devices and equipment appropriate for each individual must be used. The study further suggested that exercise interventions, cognitive behavioral therapy, and therapeutic activities appropriate to the physical characteristics of subjects who are vulnerable to falls should be provided. The fall practice guidelines published by Veteran Affairs Healthcare in the United States also highlighted the assessment of individual fall risk factors and the management of vulnerable patients to prevent falls in long-term care facilities [ 95 ]. As the proportion of adults older than 65 and the number of older adults with dementia is expected to exceed 20% in 2025 and increase to 1.27 million by 2030, studies on the assessment of individual risk factors for falls and the management of high-risk patients with dementia would need to be conducted in the future [ 96 , 97 , 98 ].

4.1. Implications for the Regulators and Future Research Agenda

When comprehensively considering trends in nursing research related to falls, falls as an indicator of the quality of patient safety in nursing has been developed and evaluated in various ways, such as for assessment tools, education and exercise programs, and nursing guidelines to prevent falls. However, there are very few translational studies to enable the prior studies to affect fall-related outcomes in clinical nursing, such as fall occurrence and fall injuries. Translational research applies basic and clinical research results as practice guidelines and protocols, compares and analyzes the effectiveness of existing and new practice guidelines, and provides education and training according to the situation in the clinical field. All relevant studies are referenced for the realization and maintenance of new working guidelines [ 99 , 100 ]. Therefore, in the future, it is necessary to conduct translational studies of falls in a nursing context, which would reflect fall risk factors, fall risk assessment tools, and fall prevention programs in the actual working environment.

4.2. Limitations

This study has certain limitations that need to be mentioned. First, to establish a search strategy that can be objectively verified at the data collection stage, we strategically searched for fall-related nursing studies with the advice of a nursing subject librarian, and only those studies in which agreements were reached between one professor and a researcher were collected to exclude studies that have used the word “fall” for different meanings. Therefore, there is a limitation that nursing studies related to falls may have been excluded from the analysis.

Second, MeSH terms were used to extract and refine words, which are the basic units of text network analysis, and words with limited MeSH terms were refined to words observed in previous studies. However, the words were expressed in various manners by different authors, and, therefore, bias in the extraction of keywords from the abstract cannot be excluded.

5. Conclusions

This study is meaningful since it presents trends in nursing research related to falls through topic modeling that may be used as basic data for future research topic development. Further research is needed to protect the safety, dignity, and rights of people at high risk and to establish policies and system development regarding fall prevention and management in medical institutions in Korea, as research in this area is insufficient compared to other countries. Finally, to prevent falls by applying existing fall-related nursing studies to actual clinical practice, it is necessary to conduct a translational study of fall-related nursing reflected in actual practice through education and training suitable for the nursing field.

Acknowledgments

This manuscript is an adaptation of the doctoral thesis of the first author.

Author Contributions

Conceptualization, Y.S. and J.-S.K.; methodology, Y.S. and J.-S.K.; software, Y.S.; formal analysis, Y.S., K.K. and J.-S.K.; writing—original draft preparation, Y.S.; writing—Y.S. and J.-S.K.; visualization, Y.S.; supervision, K.K. and J.-S.K.; project administration, K.K. and J.-S.K. All authors have read and agreed to the published version of the manuscript.

This research received no external funding.

Institutional Review Board Statement

Informed consent statement.

Not applicable.

Data Availability Statement

Conflicts of interest.

The authors declare no conflict of interest.

Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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