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ViewsThe Nurse Leader Role in Fall Prevention
By Ava Sammarco
Falls and injuries from falls are a significant problem to nurses no matter what field of nursing you are associated with. Falls and injuries from falls are in the top 10 sentinel events that affect hospitals. Falls in nursing homes and rehab facilities are one of the top-cited deficiencies. Falls at home are often the cause of hospitalization. Inexperienced nurses feel the task of preventing falls is one of the most challenging time management concerns they face. Nurse leaders often seek answers in new technology or increased staff. Experienced nurses often sigh and say “Falls happen” So, what is the solution here? How can we keep those in our care safe?
Restraints and side rails are certainly not the answer and bring their own set of challenges when used. Alarms and private sitters might seem like better solutions but they also bring their own challenges. Moving the person in your care closer to the nurse’s station might seem like the answer but not every room can be close to the nurse station. If the noise, lights, and activity keep the person in your care awake and disturbed it may even increase falls. So, what is the answer?
One Size Does Not Fit All
Discovering why people fall is one of the hardest, simple tasks you will ever be faced with. Young people, old people, healthy people, and ill people all fall. Fall prevention is not a one size fits all approach. If we try to squeeze everyone into one category, we will never be able to prevent falls and injuries from falls.
Five questions need to be answered when reviewing falls.
- What were you trying to do immediately before you fell?
- How were you feeling before the fall? [Were you dizzy, unsteady, tired, or having physical problems?]
- What do you think caused you to fall?
- Have you ever fallen like this before?
- What do you wish you would have done differently? [What will you do to prevent a fall next time?]
Identifying the reasons why a person falls will then help you to move forward in attempting to design personalized fall prevention interventions. Some interventions are easy such as assuring frequently used items are within reach. But unfortunately, not all interventions are easy or apparent.
Nurse leaders must dig hard into their thinking cap stash to find answers to this question. Using all the skills that Quality Assessment and Performance Improvement can offer.
Applying Quality Assessment and Performance Improvement Techniques:
Root Cause Analysis:
Of course, the first steps are using Root Cause Analysis. Ask yourself if this issue was resolved would the fall have been prevented. If the answer is no or even maybe; drill down further. Not all fall causes are readily apparent.
Common Causes of Falls:
- Attempting to get to the toilet
- Sudden onset of dizziness [possible causes include medication and ortho-static hypotension]
- Confusion
- Not wanting to ask for help
- Poor lighting
- Trip hazards
- Poor footwear
- Weakness caused by illness
- Sudden change in condition
- Lack of appropriate equipment or poorly maintained equipment
Once you have identified the root cause of the fall, attempt to decrease the risk by addressing the need that caused the fall. Not all risks can be eradicated. This is one of the many challenges a nurse leader will face.
Building the Perfect Care Plan:
Interventions to prevent falls and injuries from falls are as varied as the persons you are providing care for. Some interventions are commonly seen and some may be a once-in-a-lifetime intervention.
Common Interventions:
- Call light in reach
- Frequently used items in reach
- Telephone in reach
- Adequate night light in room and in bathroom
- Personalized toileting schedule
- Assistive devices in reach
- Anti-roll back devices on wheelchairs. [to prevent the wheelchair from rolling away if brakes are not applied]
- Appropriate pressure relief in wheelchair and bed
- Medication review
- Hydration
- Pain assessment
- Hip protection garment to prevent/decrease the likelihood of fracture
- Fall mat at bedside [this may increase fall risk if person’s gait is unsteady]
- Fall alarms [this may increase agitation and thereby fall]
- Private sitters
Now the potential cause of the fall has been identified and a wonderful care plan with personalized interventions has been developed. So, your person should be safe, right. Well, maybe but the best-designed care plan can not prevent falls unless the care plan has successfully identified the root cause of the problem and all involved parties including the person in your care and your staff are compliant with the interventions.
Developing and Implementing Audits
This is where nurse leaders can work their magic. Managing by walking around is an important part of Performance Improvement.
Here are some audit tools that might assist a nurse leader in identifying problems and setting the tone for future actions.
Assuring the Care Plan is the Pattern for Improvement:
This is a sample of an audit tool to assure interventions are carried out. This audit would be per client. The nurse leader would go to the client’s area and view the interventions.
Client name:____________
Date of Audit: ____________
| Intervention | Equipment is available | Staff are compliant | Client is compliant | Action taken/ Action required |
| Fall matt at bedside | ||||
| Night light in bathroom | ||||
| Call light in reach | ||||
| Water at bedside | ||||
| Wheelchair next to bed with brakes on | ||||
| Telephone within reach | ||||
| Anti-roll back device on wheelchair |
Fall Risk Assessments:
Every facility will have a fall risk assessment. This assessment doesn’t do any good if it is not completed. If the person in your care is not able to consistently answer questions. This is a time to involve families. Information about prior falls and near falls is an important part of this assessment. Completing this assessment as soon after admission as possible is also an important piece. These assessments may need to be updated often during the first days/weeks after admission.
Trends and Patterns:
Any time a nurse leader is assessing a concern it is important to monitor for trends and patterns. Don’t overlook the time of day, staff involved, area of concern [did more falls occur in a certain room or area], activity occurring at the time of fall, and even who else was present when the fall occurred. Trends and patterns can reveal a weak area or a challenge for a nurse leader to address.
Nurse leaders trying to ameliorate a concern will understand that not only is it important to identify the cause of a concern, but it is also important to see if the interventions planned are actually effective. Once the nurse leader assessments of root causes have been reviewed, assessments of trends and patterns have been evaluated, assured interventions are in place and staff is compliant with their use, the final step is “Are the falls and injuries from falls decreasing?”
But the prudent nurse leader understands that this process is not over. As with any major concern the constant cyclical approach of PDCA [Plan Do Check Act] is indicated. The audits to assure the process is working well continues. When all things are in place and a decline in concerns is noted the frequency of audits may decline. However, when concerns are again noted or increases in concerns are apparent the frequency of the audits will need to again increase.
Developing a Fall Team
This is an important part of a nurse leader’s role in fall prevention. The prevention of falls and injuries from falls is a problem that requires a team approach. Each department plays a role in preventing falls from housekeeping to clinical each team can adopt a watchful preventive role. Along with developing a preventive aspect, the team approach is important to disseminate information and cheer on participants. Each audit that indicates success should be celebrated. Each audit that shows continued challenges should be reviewed and dissected for opportunities to further improve. Team cohesion is an important part of this concern. Identifying staff invested in improving this problem is the goal of team development. Sharing the “wealth” is one tool the nurse manager can utilize in this approach. Champions of this cause can take steps to encourage others to take up the cause. This team approach often increases compliance with challenging interventions. Others on the team can take steps such as auditing, analyzing, teaching, and developing new interventions. The prudent nurse leader understands the value of teams.
Summary
While preventing falls and injuries from falls will always be a challenge, a strong nurse leader and a dedicated team can make great strides in preventing many injuries. Success in this challenge is measured in small steps. But successes can happen and when they do they “sure feel good.”
References:
Kruschke, Cheryl, Butcher, Howard Evidence-Based Practice Guideline: Fall Prevention for Older Adults. J Gerontol Nurs 2017 Nov 1;43 (11): 15-21 doi: 10.3928/00989134-2017106-01
Jin J. Prevention of Falls in Older Adults. JAMA. 2018;319(16):1734. doi:10.1001/jama.2018.4396
Radecki B, Reynolds S, Kara A. Inpatient fall prevention from the patient’s perspective: A qualitative study. Appl Nurs Res. 2018 Oct;43:114-119. doi: 10.1016/j.apnr.2018.08.001. Epub 2018 Aug 7. PMID: 30220357.
Chu, Ruby Z. PhD, RN, CCRN Preventing in-patient falls The nurse’s pivotal role Nursing: March 2017 – Volume 47 – Issue 3 – p 24-30 doi: 10.1097/01.NURSE.0000512872.83762.69
Bio‐ Sylvia Bennett-Josephson, RN, BSN, CDONA/LTC, FACDONA, CDP, CADDCT, IP-BC
Sylvia has an extensive healthcare background with more than 20 years of experience. With certifications as a Director of Nursing Administration in Long-Term Care, Master Trainer by NADONA, Dementia Practitioner, Dementia and Alzheimer trainer, as well as a fellow in Academy of Certified Directors of Nursing Administration, and a Board Certified Infection Preventionist. Sylvia brings a diverse healthcare perspective to Med-Net Compliance, LLC. In addition to her impressive professional background, she is a published author with articles featured in Mobility Now and Long-Term Living. Sylvia also is the recipient of the Spirit Award from the National Association of Directors of Nursing (NADONA) in 2013.
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The Nurse Leader Role in Fall Prevention
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Falls and injuries from falls are a significant problem to nurses no matter what field of nursing you are associated with. Falls and injuries from falls are in the top 10 sentinel events that affect hospitals.
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