Falls Prevention 1
Running Head: FALLS PREVENTION AT LINDEN GROVE
Falls Prevention at Linden Grove: Continuous Quality Improvement Project
Courtney Helman, Nicole Reinke, Tiffany Spicer, Shamay Thomas, and Lisa Wilson
Pacific Lutheran University
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FALLS PREVENTION AT LINDEN GROVE: CONTINOUS QUALITY IMPROVEMENT
Falls are the most commonly reported patient safety incident among older adults 60 years
of age or older (Oliver, 2008). For research purposes, a fall will be defined as an unexpected
event where the patient came to the ground floor or another lower level (Haines, Hill, &
Osborne, 2006; Renteln-Kruse, Krause, & Geogr, 2007). Occurrences of falls happen in several
settings, such as hospitals, long-term care facilities, and in private residences (Banez et al., 2008;
Coussement et al., 2007; Haines et al., 2006; Renteln-Kruse et al., 2007; Sorensen et al., 2006).
According to Haines et al. (2006), as many as 47% of patients in the hospital setting have
suffered from one or more falls at some stage in their hospitalization. In regards to a long-term
care facility, approximately 75 % of patients experience a fall at least once a year (Sorensen et
al., 2006). In the community setting, studies have shown that as many as 33% of seniors will
experience a fall within a year‟s time (Banez et al., 2008). Deaths due to falls were significantly
higher for older adults in long-term care facilities versus those living in the community (Bonner,
MacCulloch, Gardner, & Chase, 2007). Many factors are associated with the high rate of falls in
Risk factors for falling tend to be related to the morbidity and/or co-morbidity that the
aging population is subject to, such as gait issues, diabetes mellitus, osteoporosis, osteoarthritis,
heart disease, orthostatic hypotension, the use of certain medications, and having had recent
surgery (Banez et al., 2008). Another significant risk factor and predictor for future falls is the
patient having a history of a recent fall (Banez et al., 2008). In the long-term care facility, there
are specific hazards that put patients at risk for falling. These hazards include cluttered floors,
dim lighting, the bed in a high position, unmet toileting needs, the call light not within reach,
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lack of familiarity with the environment, no assistive device in place, and bare feet. The patient
and the facility are significantly impacted by these risk factors if they are left unchanged.
Falls are detrimental in terms of the physical and mental well-being of the patient. The
physical effects from falls may range from being non-injurious to having serious negative health
consequences, the most serious being head injuries and fractures, particularly hip fractures
(Coussement et al., 2007; Haines et al., 2006; Sorensen et al., 2006). According to Coussement et
al. (2007), hip fractures not only lead to decreased mobility and reduced quality of life (QOL),
but a significant percent of these fractures (14%-36%) may lead to death within one year. Even
the physically non-injurious falls have a considerable impact on the well-being of the patient.
According to Coussement et al. (2007) and Banez et al. (2008), after a falling event, patients
often experience a “fear of falling” which then leads to decreased activities of daily living
(ADLs), increased dependency, and the possibility of residing in a long-term care facility.
Monetarily, falls cost both the patient and the facility. Recently, Medicare, the United
States federal government insurance plan for paying hospital and medical expenses, has
implemented changes to reimbursement in regards to injuries related to falls. Medicare will no
longer pay for injuries or hospital acquired illnesses/diseases they deem due to hospital
negligence, which includes patient falls (Skriloff, 2007). It is easy to predict that other insurance
agencies may soon follow the example set by Medicare if they have not done so already. A
sobering fact concerning the price of falls is the “life-time cost associated with fall-related
injuries (direct, morbidity and mortality) in the elderly… [which has] been estimated [at 12.6
billion dollars], approximately 6% of all medical care expenditures for the elderly” (Sorensen et
al., 2006, p. 252).
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We chose this topic for the quality improvement project because as a preventable event, it
speaks directly to the nursing scope of practice. Nurses are in the unique position to apply
evidence-based practice to significantly increase the quality of life for the patient and decrease
health care cost for the agency. We will be utilizing the nursing process as a framework for our
quality improvement project.
Assessment is the initial phase of the nursing process. During this phase, information is
gathered about the individual, family, or community. In our case, information was gathered
regarding prevalence, cause(s), and prevention of falls in a long-term care facility, Linden Grove.
To properly assess the problem, we employed several strategies. Our group obtained data on the
prevalence of falls at the facility. We conducted a literature review to further investigate the
topic. Both subjective and objective data were collected for analysis, including interviews,
questionnaires, and general observations. Lastly we conducted a systems analysis to identify the
environment, raw material and energy that make up the parts of the facility as a whole.
Linden Grove has the capacity to hold 130 patients. At the time of the preliminary
assessment, there were 103 patients, but according to staff, on average, the facility has
approximately 110 patients. On our initial assessment, we discovered that the amount of falls
reported in 2007 was 396. Nursing and support available for patient transfers included 6
registered nurses (RN), 60 nursing assistants certified (NAC) and 26 licensed practical nurses
(LPN). Our assessment guided the focus of the following research questions: What was the cause
for the considerable amount of falls at this facility? Were falls related to patient handling,
transfers by staff, patients transferring themselves, or a facility issue such as lack of staff,
training, or equipment? Based on the initial assessment we formed several hypotheses.
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Our initial hypothesis was that falls were due to staff transferring techniques, particularly
NAC‟s not having adequate training to provide safe transfers. In addition, we considered that if
there is a high patient to NAC ratio at Linden Grove this could adversely affect transfer
techniques due to caregivers rushing during assists. Our group also hypothesized that the
investigation would find increased staff injuries due to patient handling. From our hypothesis,
we initiated an in-depth investigation into falls.
Objective data is an important component for obtaining factual clues. We obtained
objective data regarding the causes of falls at Linden Grove. Data was collected by reviewing
the current literature, and observing the building, rooms, and staff/patient interactions. In
addition, researchers reviewed the facilities Falling Star Program. The Falling Star Program
aims to identify and initiate interventions if a patient is at risk for falls. Included in the
assessment of the Falling Star Program was the falls risk assessment tool used by nurses to
identify patient falls risk. Furthermore, we sought evidence of visual cues (signs) for reminding
patients and staff of patients‟ fall risk.
We found a number of research articles from several disciplines including nursing,
business, medical, occupational therapy, and physical therapy. Originally, articles were included
if they addressed fall risk and prevention preferably in a long-term care facility with a targeted
age range of over 60. We then added articles with populations in places other than long-term care
facilities because information for a long-term care facility can be inferred from the other settings.
Other articles addressed ergonomics, staff training, intervention programs, patient education, on
the job injuries, and environmental factors related to transfers. These topics guided our
observations of the facility.
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Upon observation of Linden Grove, we found some general safety measures in place,
such as call lights within patients reach and in patient‟s bathrooms. An additional safety measure
observed was handrails in hallways and bathrooms for patient assistance. However, many rooms
were cluttered with personal belongings and oversized furniture which are potential fall hazards.
We did not identify many visual cue signs, but Lisa Johnson RN, the director of nursing, stated,
“Many of the visual cue signs we have are in the bathrooms” (Personal communication,
September 23, 2008). Another potential hazard related to falls noted was the congested common
area where patients sit and socialize. Patients were seen trying to push past other patients in these
areas. While at the facility, we witnessed a patient fall due to their mishandling of their four-
wheel walker. The response by a RN and NAC was immediate, and we observed a physical and
cognitive assessment. Though helpful, after our observations, we recognized that additional
objective data was needed.
We assessed the Falling Star Program by reviewing the program criteria, the falls risk
assessment tool, and examples of fall prevention signs that are placed in patient rooms. The
Falling Star Program criteria stated that the purpose of the program is to identify “triggers which
warrant implementation” and to “standardize parameters for initiation” (See Appendix A). In
addition, the criteria contained minimal interventions, frequency of assessment for continuation
of the program, and case manager referrals to restorative care when needed.
The fall risk assessment survey tool is a part of the Falling Star Program and addresses
fall risk by appraising several contributing factors of falls including: level of consciousness
(LOC), history of falls, ambulation/elimination status, vision status, gait/balance, systolic blood
pressure, medications, and predisposing diseases. Numerical scores ranged from 0, which
signifies no fall risk, to 37 which signify the highest falls risk. Criterion to be placed on the
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program is a score of 10 or greater. In addition, the questionnaire inquires about the patients‟
ability to perform activities of daily living. Though this survey tool addresses falls risks, we are
not aware of its effectiveness as a diagnostic tool because it is not a tool that we are familiar with
(See Appendix B).
Subjective data is also an important component of the assessment process. After consent
was obtained, subjective data was collected by two different survey techniques. First a survey
with open-ended and Likert-scale questions for LPNs and NACs was distributed (See Appendix
C). Secondly, interviews were conducted with managers (See Appendix D). Justification for the
sample size was based on the expert advice of a nursing school faculty member (E. Mize,
personal communication, October 9, 2008). Faculty member Emily Mize aided us in determining
sample size as a representative sample of our population. A convenience sampling method was
used to obtain participants for the survey.
Protocol for data collection included informing Lisa of our intentions of data collection
by survey methods, and she informed the charge nurses. The charge nurses told the rest of the
nursing staff about the surveys. Surveys were placed at the nurses‟ station, a central area were
LPNs and NACs congregate. In addition to the LPN and NAC survey, five interviews were
conducted. Those interviews were completed at the convenience of the managers which included
the director of nursing, a RN, the therapy department manager, a physical therapist (PT), a unit
manager, a LPN, the restorative aid coordinator, a LPN, and the temporary building manager, an
advanced registered nurse practitioner (ARNP).
In general, due to our initial assumption of inadequate staff training regarding transfer
techniques, the LPN and NAC survey mainly addressed training and lifting techniques of the
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NAC‟s. However, we also asked about the use of mechanical lifts, prevalence of injuries due to
transfer assist, and having witnessed patients fall. Questions we included in management
interviews in addition to staff training were questions regarding whether there was a transfer
method in patient care plans, any evidence of staff injuries due to transferring patients, and what
they thought falls were related to. All these questions were an attempt to understand the reason
for falls at Linden Grove.
To better understand Linden Grove, we employed the use of the multidiscipline systems
theory adapted from Ludwig von Bertalanffy, “General System Theory.” The theory attempts to
explain “productivity in terms of a unified whole as opposed to a series of unrelated parts”
(Yoder-Wise, 2007, p. 122). The long-term care facility, Linden Grove, interacts with both
internal and external influences. Our group will focus on the interplay between these influences
described as inputs, throughputs, and outputs (Bertalanffy, 2008).
We recognized inputs as follows: federal, state, and local laws, Medicare and Medicaid
policies and reimbursement requirements, the Washington State Nurse Practice Act, and
Washington State‟s regulatory boards. Additional inputs include patients and families, money
from fees and cost of care, health care workers and other staff, access to the World Wide Web,
and other technology such as equipment in the form of mechanical lifts. We identified
throughputs as institutional policies and mission statements, nursing and staff roles and
functions, patient therapy (speech, occupational, and physical), and other activities including day
trips, housekeeping, on site meal preparation, and management‟s focus on effective and efficient
services. Lastly, outputs that we generated included informed patients, patients involved with
their health care, satisfied employees, quality patient care, and changes in nursing roles
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(business, management, and technology fields) due to the demand for creative solutions for
efficient and successful health care outcomes.
Analysis and Synthesis
To produce a plan to implement change, we first performed an analysis and synthesis of
the assessment data. We utilized several strategies for this aim, including a synthesis of the
literature to address the scope of issues. Furthermore, we identified gaps and incongruities in
data. Also, causal relationships were identified to assist in concluding if change was needed and
what exactly needs to be improved. Moreover, Lewin‟s Force Field analysis was conducted to
categorize the forces that complemented or hindered the proposed improvement. Three of
Deming‟s management theory points were discussed to address our goal of total quality
management (TQM). Finally, we produced nursing diagnoses from the analysis and synthesis of
the assessment data for the next step in the nursing process, planning for change.
On analysis of the literature, we identified patient-centered education and identification
of risk factors as the best method for preventing falls, perhaps even greater than supplemental
staff training. According to Jeske et al. (2006), there is limited research that has been conducted
on the effects of patient and family education for preventing falls. After implementing a patient
and family education program, a reduction in fall rates was observed (Jeske et al., 2006). The
Haines et al. (2008) study argued that patients modified their behavior following patient fall risk
education sessions. Subsequently, by modifying their behavior, there were less falls. According
to the meta-analysis of Coussement et al. (2007), their findings suggest that identifying a
patient‟s risk factors is the most useful intervention for reducing falls. On analysis of the
literature review, which was supported by management survey responses, we began to recognize
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that the data suggested that the best focal point for changing patient falls is related to their lack of
knowledge and identifying risk factors regarding their ability to self-transfer. Before we could
draw conclusions, our group had to identify gaps and incongruities in the data.
On early analysis of respondents‟ surveys and interviews we identified gaps and
incongruities in data. Initially we failed to recognize that the two survey tools used (LPN and
NAC survey and managers interviews) were not standardized. For example, managers were
asked what they thought patient falls were related to, but we failed to ask the NAC‟s who work
directly with the patients that same question. As another example of incongruent data collection,
our surveys asked LPN‟s and NAC‟s if they had ever witnessed a patient fall, but we did not ask
managers the same question.
In reference to additional gaps in data, though it would have greatly benefited us, we
decided to not survey patients because they are a vulnerable population. When surveying a
vulnerable population for scholarly inquire, an ethics committee must be involved for patient
safety. We believed that to obtain approval from the human participant review board (HPRB) an
ethics assurance committee of Pacific Lutheran University would have been too time consuming
for the amount of time allotted. In addition, our professor, Dr. Schultz, said it would not be
necessary to collect the additional data from patients (C. Schultz, personal communication,
September 24, 2008).
Further trouble we found in data analysis included that certain survey questions were
worded ambiguously. For example, on the LPN and NAC survey we asked what type of training
the staff received. The varied participant responses made it obvious that we had not been specific
enough and should have specified the question as transferring or lifting training. Furthermore, on
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the LPN and NAC survey, we asked, “Have you ever used a transfer device at work to move a
patient?” We left the interpretation of what type of transfer device up to the participant. The
facility‟s unwillingness to give us cost information regarding falls was another gap in assessment
data. Identifying these weaknesses in data collection prevented us from making causal
relationships from these surveys without due consideration.
Regarding the LPN and NAC survey, 15 out of 18 reported they felt adequately trained,
which directly countered our hypothesis. When asked if they felt safe while transferring, all but
one said they felt safe either “often” or “always” (See Appendix E). Regarding injuries, 14
replied that they had not been injured and 4 said they had been injured during a transfer. When
asked if they have witnessed a patient fall, 6 out of 11 replied yes (See Appendix E). Regarding
the use of transfer devices, all said they used them sometimes, often, or always. One respondent
did claim, “I don‟t know.” There were a few open-ended questions for elaboration regarding
training, lifts, injuries and transfer devices. We did not find any significant responses pointing to
inadequate staff training in these answers.
To summarize the five management interviews, all responded that NACs had some type
of training on lifts with orientation. When asked if NACs need more lift training, two responded
yes, two responded on an as needed basis, and the LPN unit manager replied no. All responded
that the transfer method was in patient care plans, and believed the NACs were using the lifts
properly, at least most of the time. Four admitted that the NACs and nurses were experiencing
on-the job injuries, and one responded that the injuries may be due to slips. When we asked
management, “What do you feel falls were related to?” All responded that falls were due to
patients self-transferring in one form or another.
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To our surprise, the analysis and synthesis of the research assessment did not support our
initial hypothesis of inadequate staff training and improper lifting or falls caused by transfer.
Though there were inherent weaknesses of data collection, such as the use of a convenience
sample for obtaining a representative population for survey, which is often regarded as having
inherent biases, we could still recognize two overriding themes of participant responses and a
theme to our observations.
LPN and NAC responses indicated that they either had enough training or believed they
had enough training, and all managers responded that falls were due to patients trying to self-
transfer. In addition, we witnessed cluttered rooms and patients rushing in congested common
areas. Moreover, in review of the Falling Star Program, there are no interventions in place other
than identifying an at risk patient by placing a star on their door and wheelchair and putting up
visual cue signs in their room. We argue that the evidence supports focusing on patient and staff
education for implementing change. Rationale is that survey respondents did not confirm the
initial hypothesis of inadequate staff training. Instead the research pointed towards patients being
unaware of their inability to ambulate and self-transfer and unaware of the fall hazards in their
rooms and common areas. In addition, research pointed towards staff‟s unawareness of
interventions of the Falling Star Program. Our group focused on the patient‟s lack of knowledge
for improvement as well as staff being uninformed regarding the protocol for falls risk patients.
Having a clearer idea of the primary influence contributing to falls at Linden Grove, we
did a force field analysis according to Lewin‟s change process to determine driving forces and
resisting forces, which helped in planning for change. Driving forces assist and complement the
change that is to take place, while resisting forces hinder and clash with the change taking place.
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We consider a driving force to be internal management policies and facility rules that
support investigating and changing the incidence of falls at Linden Grove. The facility already
having a falls prevention program was also a driving force for enhancement. Other driving forces
influencing this change were the manager‟s attitudes. For example, the therapy department
manager, Alison Kolp, and Lisa were exceptionally supportive. They assisted in identifying the
issue that needed to be improved and facilitated our data collection, respectively. We identified
additional resisting forces as the defensive attitudes and abrupt interview answers of some of the
respondents. For instance, when one of the LPN managers was interviewed, she gave terse
answers with a defensive stance.
To help further analyze management issues that will influence our journey towards
quality improvement, we analyzed Deming‟s 14 points of management theory. The 14 points are
for optimizing transformation of an organization whether industry, education or government
(Douglas & Frendendall, 2004). Though not in any particular order of importance, the three
points we focused on which directly pertained to influencing change at Linden Grove were the
5th, 8th, and 14th points.
Deming‟s fifth point refers to management constantly improving processes for service.
(Douglas & Frendendall, 2004; Anderson, Rungtusanatham, & Schroeder, 1994). According to
The first component that this point encompasses is to search continually for problems in order to
improve every activity in the company. The undisputable fact is that there were 396 reported
patient falls at Linden Grove last year. This is a problem in which some action needs to be taken.
When this problem is addressed and the number of falls is reduced, quality and productivity will
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Another concept Deming‟s fifth point addresses is that through improving constantly,
management is also searching to constantly decrease costs. Falls are costly to the agency,
therefore there is a need to prevent falls to decrease the costs of injuries sustained when a fall
Another part of improving constantly is instituting innovation of products, services or
processes (Douglas & Frendendall, 2004). Instead of completely changing the falls prevention
program that Linden Grove has in place, we will be collaborating with them to improve this
process. We need to innovate and improve their process of falls prevention because 396 falls a
year is a problem and their process of falls prevention needs improvement.
The last component of the fifth point is in regards to the specific role that management
plays. It is management‟s job to work continually on the system. We worked in collaboration
with the management at Linden Grove to reevaluate what is being done to prevent falls and
design what else can be implemented to prevent falls from occurring.
We believe that Deming‟s eighth point, “to drive out fear”, pertains to this facility‟s
attempt to improve quality of services (Douglas & Frendendall, 2004; Anderson et al., 1994).
This point encourages effective two-way communication and other means to drive out fear
throughout the organization. As a result, everybody may work effectively and more productively
for the company. It was not only important to have open communication between staff and their
patients, but between staff and top management as well. In order to have open communication,
trust must be established. We observed what may have been an issue in communication between
upper management and staff. Top management was excited and helpful towards our proposed
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quality improvement project compared to other staff which we perceived as defensive and
Due to our group not establishing trust with the nursing staff, some felt that their job
performance was being scrutinized unfairly. We wondered if some staff perceived this quality
improvement project as implying they were not doing their jobs correctly. Management was in
alliance with us because negative patient outcomes such as falls directly reflect on their
performance. However, in our excitement for this project, our group may have neglected to
assure staff that we were to be tools for positive change. We were not seeking to identify which
staff were inadequately performing their job. In order to drive out fear, the whole organization
needs to work together and develop rapport. If we ensure a safer facility and educate patients on
how to reduce falls, without making anyone “wrong”, we believe this objective will be fulfilled.
The last part of Deming‟s eighth point is encouraging communication so that everybody
may work efficiently in the company, which is the inevitable outcome of open and honest rapport
(Douglas & Frendendall, 2004). If this collaboration with management and staff were achieved, a
decline in the number of falls per year would occur and improve quality care. With less falls,
everyone will be able to focus on improving other tasks and not have to deal with the
repercussions of a fall.
Deming‟s fourteenth point addresses the top management‟s commitment and action in
bringing about quality improvement. We analyzed management‟s commitment to improve
quality and productivity, and their obligation to implement all of these principles (Anderson et
al., 1994). It was evident to us that management was concerned about patient safety and the
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amount of falls at the facility. To confirm this, managers facilitated our investigation and were
often available for support in the implementation of the project.
Another feature of the fourteenth point is that the organization must commit themselves
to the transformation and take on the common goal (Anderson et al., 1994). If we attempted to
implement our original idea (staff training or retraining), staff and management beliefs would be
a significant barrier to change. This is because our assessment demonstrated that there wasn‟t a
need for transfer training. If the nursing staff believes that falls were not related to their actions,
why would they want to commit to more time spent on training? In developing a new plan to
implement, we aligned our goals with those of the organization.
Everyone needs to be involved and team work must be in place to accomplish
transformation. In order to assist in the organization‟s transformation, we had to work in
accordance with the staff and managements belief systems to gain a meaningful commitment to
quality improvement. We agree with Deming‟s point, that everyone needs to be involved, and
team work must be in place to achieve quality improvement. (Anderson et al., 1994). If a plan
was made to educate patients on falls, the whole organization would need to work together to
implement the plan and achieve the best patient outcomes.
To achieve the best patient outcomes, we identified two nursing management diagnoses
which were applicable to Linden Grove for the quality improvement project. (1) Ineffective
health maintenance related to inadequate patient education regarding fall prevention as
evidenced by number of falls at Linden Grove in 2007. (2) Increased health care cost related to
complications from patient falls as evidenced by annual spending on surgical and rehabilitative
procedures, as well as inpatient care.
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As mentioned in the analysis and synthesis, our group came up with two nursing diagnoses that
best suited the problems found related to falls as determined by the assessment and the literature.
The first diagnosis is:
Ineffective health maintenance related to inadequate patient and staff education regarding
fall prevention as evidenced by number of falls at Linden Grove in 2007, and key
informant, Lisa, stating that staff is unaware of the Falling Star Program and the
interventions required in response to a fall.
The long term goal for this diagnosis is: Decreased number of falls in 2009 as
compared with the number of falls in 2007 and 2008.
■ One short term goal for this diagnosis is: increased number of patients with falls
The objectives to meet this goal include: 100 percent of patients will have
falls prevention (visual cues) signs in their rooms and have received education
about these signs by December 2008.
■ Our second short term goal is: Increased number of staff with falls prevention
The objectives to meet this goal are: 100 percent of staff will have received a
falls prevention brochure by December 2008 and 100 percent of staff will be
able to verbalize what they can do to prevent falls by December 2008.
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The plan we created to implement the objectives and meet the first short term goal
consists of creating a visual cue sign to place in the patient‟s room that says: “STOP! Use Your
Call Light, WAIT For Help,” to remind the patient how to prevent falls. According to Lisa A.
Cranwell-Bruce, MS, RN, FNPC, “A number of intrinsic and extrinsic factors affect elders‟ fall
risk. Visual impairment, urinary frequency, impaired balance or gait, changes in cognition,
orthostatic hypotension, and environmental hazards can contribute to falls in older adults”
(Cranwell-Bruce, 2008, p. 189). Our hope is that these signs will address some of these factors to
prevent falls. For example, if a patient has orthostatic hypertension they will see the sign placed
in their room and remember to ask for help before they get out of bed. The signs are large with
large font and simple sayings so that the patients can read them without difficulty. They are the
shape of a stop sign which will get the patient‟s attention. In a study where the researchers, Jeske
et al. (2006), implemented a similar project their findings were as such:
Twenty-one (81%) patients and families stated that the poster caught their attention. In
this group, one person could not read the words but understood the stop sign. Twenty-two
(84%) patients thought that the poster was an effective idea for fall prevention, and 24
(92%) patients stated that the directions were easy to follow and would help to prevent
falls (pp. 239-240).
We generated several designs for the sign. This research helped determine which design for the
sign would be the most effective. It is important for the sign to be easy to see and understand.
Upon the assessment of Linden Grove, it was noted that they currently do have signs in select
patient rooms, but they are all white with black writing and do not stand out. (See Appendix F)
Therefore, new signs are needed because patient education is important. Studies show that
patient education can significantly decrease a patient‟s risk for falling.
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A study by Haines et al. (2006) used a patient education program with a component that
was similar to the signs and brochures that we created. He said, “participants were provided with
the „three simple steps to stopping falls‟ (i.e. to know if they need help to mobilize, to ask for
help if required, and to wait for the help to arrive) and other practical advice to enhance their
safety” (p. 972). According to Haines et al. (2006), this program decreased the incidence of falls
within the population studied:
There was a significantly lower incidence of falls in the intervention group relative to the
control group, both when the analyses included all participants who received any
combination of the interventions that included the education programme, or
when...including those who received the education programme only (p. 974).
A surprising result of this study was that patients who were cognitively impaired, as
determined by a Mini Mental Status Exam score of 23 or less, benefited the most from the
patient education program. The researchers stated that they believed that this was due to the fact
that people with decreased cognition are more likely to fall and therefore benefit more from
programs designed to decrease falls. They also stated that they believe that although these
patients were somewhat cognitively impaired, it was not to the extent that they were unable to
interpret and follow directions (Haines et al. 2006). For the plan being implemented, the aim is
that the education provided to the staff will be sufficient to decrease falls in patients whose
cognitive ability prevents them from benefiting from the sign in their room and the patient
education provided to them.
Our group created a brochure that explains the facility‟s Falling Star Program. The nurse
manager, Lisa, has been very supportive of this idea and has emphasized a great need for
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education of staff about this program. Lisa gave us input and recommendations for the content of
the brochure. The intention for creating a brochure is to increase the staff‟s knowledge
concerning the Falling Star Program, how to prevent falls, and to support the staff in being
proactive in preventing falls. A model similar to the program we are improving was created by
Bonner et al. (2007). They led a group of students in a study that developed interventions to
decrease falls in a long term care facility. In this study they trained staff and had them teach
others about falls prevention, “Following the educational session for staff, champions were
identified and trained to lead the fall prevention program, including providing instruction about
falls prevention and appropriate interventions” (p. 313). We are working in collaboration with
the staff at Linden Grove to improve the program. Also, rather than generating an entirely new
program to prevent falls, our group will be educating the staff of the program already in place by
making the information more readily available.
In a study done by Bare, Corcoran, Johnson, and Lopiccolo (2008) in a long term care
facility in Illinois, staff education was key in reducing the incidence of falls. To educate the staff
members, they showed them pictures of potentially dangerous situations with the words “I‟m not
falling for that” stamped across the images (p. 91). They wanted to make sure staff was very
clear on what to look for to prevent falls. They also incorporated all staff members, but mostly
important, Bare says, “Is the empowerment of all staff to intervene in dangerous situations. Staff
at Briarwood understand that preventing falls is the job of every employee, not just nurses” (Bare
et al., 2008, p.91). The education that was provided to the staff worked in decreasing fall rates,
“Over a period of three months, the incidence of falls decreased 50%, Bare says. Also, the
number of injuries related to falls fell by 50%” (Bare et al., 2008, p. 91). The decrease in falls is
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not only important to the well-being of the patient but it also benefits the facility. A decrease in
falls lowers the amount of money spent on injuries related to patient falls.
The second nursing diagnosis is:
Increased health care costs related to complications from patient falls as evidenced by
annual spending on surgical and rehabilitative procedures, as well as inpatient care.
o Our long term goal for this diagnosis is: Decreased cost of health care related to
injuries sustained during patient falls.
Linden Grove did not release any information regarding money spent on patient falls or
injuries related to patient falls. Therefore the cost analysis will be handed over to them to
determine if the goals and objectives were met. The same short term goals and objectives will be
used for this diagnosis as for the other diagnosis because research shows that an increased
incidence of falls positively correlates with increased costs, therefore if we have interventions in
place to decrease the amount of patient falls it will also decrease the cost. An article from the
Orange County Business Journal stated that for a serious patient fall it would cost at least
$15,000 to $30,000, and that‟s only for rehabilitation (Reed, 2005).
With fall prevention interventions in place, nursing staff are less likely to sustain injuries
related to their response to patient falls. During the preliminary assessment at Linden Grove we
inquired about the impact of falls on the facility. Here are their questions and the results: “How
many on the job injuries occurred in the last year? There were seven total on the job injuries
related to moving patients, two during transfers and five during repositioning.
Falls Prevention 22
How much did this cost the facility? This resulted in 47 lost time days and 91 light duty days.
The company does not want to divulge the money it cost for these injuries.”
According to a study done by O‟Reilly, Achimore, and Moore-Dawson (2001), “Lifting
is the single most important occupational risk factor associated with low-back injury. Patient
lifting has long been identified as the primary occupational back stressor for nursing personnel”
(p. 508). Staff injuries can be very expensive as well, therefore the interventions will help
decrease the costs of nursing injuries. The nurses will not be as likely to rush to the aid of the
patient who has, or is about to fall, and attempt to hurriedly grab on to them using improper body
mechanics which could lead to an injury. “Estimated costs for back injuries are between $24 to
$64 billion dollars annually” (Guthrie et al., 2004, p. 80).
As of this year Medicare is no longer paying for health ailments that are considered
preventable. As noted in the Hudson Valley Business Journal:
Medicare no longer will pay for the following conditions if they occur on the hospital‟s
watch: objects (like sponges) left in a patient during surgery; blood incompatibility; air
embolism; falls; mediastinitis (an infection that can follow heart surgery); urinary tract
infections from using catheters, pressure ulcers, or bed sores; and vascular infections
from using catheters (Skriloff, 2007, p. 14).
This is another factor that has the potential to greatly increase the costs of patient falls.
During our planning process, one alternative that was considered included, making an
educational video to teach the staff how to use lifts and other transferring devices. This
alternative was not chosen because the assessment revealed that the problem was not that the
staff was contributing to patient falls by their lack of knowledge but that the patients were
Falls Prevention 23
contributing to their own falls by attempting to get out of bed without any help. We also
considered creating badges for the nurses, but we decided not to follow through with this
alternative. Making a brochure to put in the patients‟ rooms was also considered but decided
against because the research suggested the simpler the better therefore a sign seemed more
appropriate. We thought about putting signs on the doors for the CNAs but decided against it
because Lisa said that the doors would be too cluttered and the signs would not have very much
of an impact. She instead suggested the brochure for staff.
The actions that we have taken to accomplish the goals that we have outlined are:
Create visual cues signs that are red in color and have the sayings “STOP! Use Your
Call Light, WAIT For Help” (See Appendix G).
We have printed and given these signs to Lisa to place in the patients' rooms.
We created brochures explaining the Falling Star Program (See Appendix H).
These brochures include:
o Techniques for decreasing the severity of injury for high falls risk patients.
o Suggestions for decreasing the amount of falls in all patients.
o An outline of the falling star program.
o Things to look for when determining whether a patient is at high risk for
Falls Prevention 24
We have printed out the completed brochure and given it to Lisa to hand out to staff at
In order to implement the changes that have been discussed, certain leadership and
management skills have been required. Effective communication has been essential, not only
among our group but between them and the staff at Linden Grove as well. In the communication
process there have been some barriers at various times that the we have had to overcome, such as
perceptual differences, and semantics. For example, there were occasions where a group member
was uncertain about what their assignment entailed, and another time when someone was unsure
of a deadline. In these instances the group followed Hersey and Blanchard‟s Situational
Leadership theory (http://changingminds.org/disciplines/leadership/styles/situational_leadership_
hersey_blanchard.htm). They became directing if a researcher needed it, they were always
supportive, which encouraged the researcher to accomplish the tasks delegated to them. There
was always constructive feedback regarding the tasks at hand, but there was not micromanaging.
There was consistent communication between us and the staff at Linden Grove,
specifically the nurse manager, Lisa. As mentioned earlier Lisa suggested that we create a
brochure to provide education for the staff on the Falling Star Program. Through our
communication with her we learned what would be the most useful and effective in decreasing
falls. We had other ideas that we were eager to implement but by efficiently using the
communication process rather than making decisions based on our own preconceptions, we did
what would be the most successful, and incorporated the community with which we were
Falls Prevention 25
A management skill that we utilized was delegation. Our group consisted of five nursing
students with different schedules; therefore, delegation of tasks was necessary. We assigned the
workload in accordance with each group members‟ clinical schedule and what work outside of
the project was required of each of us, so that none of us became overwhelmed or unable to
complete our tasks. Each member of the group proved to be very capable of the tasks at hand
therefore there was rarely a need for coaching or directing. There was however, feedback and
constructive criticism. There was a designated leader for each half of the semester. The leader,
with the help of the group, made sure that tasks were delegated, and kept the group on schedule.
If the leader was not on schedule then the group would assess the needs of the leader and direct
the leader to where they should be.
We selected Hersey and Blanchard‟s Situational Leadership theory because it was the
most appropriate model to use within the group. Group members chose to adapt their leadership
style in accordance with the circumstances and became directive or supportive towards other
group members, depending on what was needed. We were not consciously aware that they were
using the Situational Leadership theory. It was only in looking back that we realized that we had
used this leadership style. We found that changing our leadership style in accordance with our
circumstances accomplished the most and helped us function effectively as a group.
To implement a program that will improve the quality of care and economically benefit
Linden Grove we used Gardner‟s Tasks of Leadership. The first task is envisioning goals, which
is done by “assisting staff in formulating their vision of enhanced clinical and organizational
performance” (Yoder-Wise, 2007, p.16). This was accomplished by initially listening to their
stated needs and brainstorming plans to meet them. We then did an assessment and determined
Falls Prevention 26
that our original plan would not meet their need so we adjusted it accordingly by working with
them to determine what their goal was and how we could best meet it.
The second task is affirming values, which is defined as “Assisting the staff in
interpreting organizational values and strengthening staff members‟ personal values to more
closely align with those of the organization” (Yoder-Wise, 2007, p. 16). The program that we are
implementing is outlining the falls prevention protocol for Linden Grove that is not being
followed by the staff. Our aim is to educate the staff on the importance of the protocol that
Linden Grove has put in place to implement their value of safe patient care.
The third task is motivating. According to Gardner (2005), there are specific factors that
motivate individuals and groups; he says:
At the heart of sustained morale and motivation lie two ingredients that appear somewhat
contradictory: on the one hand, positive attitudes toward the future and toward what one
can accomplish through one‟s own intentional acts, and on the other hand, recognition
that life is not easy and that nothing is ever finally safe (p.4).
To motivate the staff at Linden Grove we appealed to their sense of responsibility for patient
well-being as well as sense of accomplishment in decreasing the amount of falls.
The fourth task is managing, which is our role in this program. Yoder-Wise (2007)
defines managing as “Assisting the staff with planning, priority-setting, and decision making;
making sure that systems work to enhance the staff's ability to meet patient care needs and the
objectives of the organization” (p.16). With the help of Lisa we have developed a plan to
accomplish the organizational goal of increasing safety and decreasing cost related to patient
falls. We have worked out the logistics, which are the small steps required to meet the objectives
Falls Prevention 27
and eventually accomplish the long term goal. Gardner (2005) separated managing into five
different parts. One of those parts is: organizing and institution building. Regarding this he said,
Someone has to design the structures and processes through which substantial endeavors
get accomplished over time. Many who have written on leadership have noted that,
ideally, leaders should not regard themselves as indispensable but should enable the
group to carry on. Institutions are a means to that end. Jean Monnet said, “Nothing is
possible without men; nothing is lasting without institutions” (p. 5).
Through acting as managers we have created a plan that does not require our continual
intervention because we want a safer environment to become a policy within this institution. We
are not trying to create a transient ideal that will leave the institution as soon as we do.
The fifth task is achieving workable unity, which is defined as, “assisting staff to achieve
optimal functioning to benefit transition to enhanced organizational functions” (Yoder-Wise,
2007, p.16). We have accomplished this by listening to the nurse managers and staff members,
working to tie together the values of the institution and the staff through the falls prevention
program, and motivating the staff to work together to achieve a mutual goal. Similar tactics were
used to accomplish the sixth task, which is developing trust. Through the behaviors listed above
we showed them that we are genuinely interested in developing a program that will serve their
best interest, rather than to fulfill our agenda.
The seventh task is explaining, which is “teaching and interpreting information to
promote organizational functioning and enhanced services” (Yoder-Wise, 2007, p.17). In
creating the brochure on the Falling Star Program we are explaining to the staff at Linden Grove
how a patient is placed on that program, and telling them what to do if they are working with a
Falls Prevention 28
patient who is a falls risk. The visual cue signs in the patient‟s rooms are explaining to them
what to do to prevent falls. We are using the task of explaining to accomplish our goals. The only
change that we are implementing is clarifying and emphasizing the importance of falls
prevention strategies to the staff and patients.
The eighth task is serving as a symbol. The best way to describe this is by using an
example that given by Gardner (2005). When talking about a friend of his who had recently
switched roles from being a professor to becoming the president of the college where he worked,
he mentioned that during his friend‟s first speech as president the audience did not respond well.
His friend told him that he had spoken no differently than how he would have normally, and
Gardner told him that was the problem. The audience had expected him, in his new role, to act as
their symbol rather than talk about his own views. Gardner (2005) said,
I told him gently that they had expected him to be their spokesman and symbol, and this
simply angered him further. “I‟ll resign,” he said, “if I can‟t be myself!” Over time, he
learned that leaders can rarely afford the luxury of speaking for themselves alone (p. 8).
Our group ran into a similar problem as Gardner‟s friend. Before we had done our assessment we
had our own view of what needed to be changed. Through our assessment and collaboration with
the staff at Linden Grove we learned the true focus for improving falls centered on patients‟ self-
transferring, and we changed our direction accordingly. In doing so, we became a symbol for the
staff and patients at Linden Grove.
The ninth task is representing the group (Gardner, 2005). Our group has not specifically
had an opportunity to represent the staff or patients formally; however, we are representing their
needs. The tenth and final task is renewing (Gardner, 2005). Due to time constraints we will not
Falls Prevention 29
specifically be able to complete this task but if time allowed we would re-evaluate the
progression of the program we are implementing and reassess its effectiveness. We have
however encouraged Lisa to continually evaluate the effectiveness of the program.
To fully evaluate the effectiveness of the program being implemented we require an
extended period of time, therefore the evaluation will only be up to the point of handing the
project over to Lisa, the director of nursing at Linden Grove. This extra time is needed because it
will take an entire year to determine whether our program has been successful. We need a full
year to collect data regarding the program we‟ve implemented and the program‟s effect on
patient falls in order to compare information to patient fall data from previous years. The
brochure and the sign that we created have been handed off to Lisa who is going to take the next
step and distribute them to the staff as well as place the signs in all patient rooms. Lisa has
agreed to collect data on patient falls in the upcoming years and compare it with past data.
As a group we evaluated the effectiveness of our leadership style and determined that we
have accomplished the goals that we set in the beginning. We did this by assessing and meeting
everyone‟s needs. We held meetings at least once a week to discuss progress and goals for the
upcoming week. At these meetings we made an agenda and delegated the appropriate tasks to
each group member to complete in coordination with our timeline. This was effective for us
because it clarified responsibilities and kept everyone accountable. We were effective because
each of us had our voice heard and never felt that we couldn‟t express our feelings or opinions
regarding the project. We were able to create and complete a valuable program because we
Falls Prevention 30
strongly valued input from staff at Linden Grove and listened to their requests on what they
wanted to have improved.
We assessed each other‟s strengths and weaknesses. We made it a point to learn from
each other‟s strengths and we also developed our areas of weaknesses. One example of this was
choosing a leader that would not typically volunteer to be or be chosen as a leader. Along with
this we encouraged trust and followership in those who would normally take on the leadership
role. We allowed everyone to express their opinions freely, encouraging those who usually do
not express opinions as frequently to do so, and encouraging those who primarily dominate
conversations to step back.
This project gave us many opportunities to grow. We learned that even as students we
can make a difference that will actually improve patient outcomes within an organization. The
quality improvement process showed us the importance of collaborating with an organization
and the importance of letting the assessment determine the outcomes rather than our
preconceived ideas. Through this new understanding we were able to formulate our goals and
objectives around the needs that we saw, rather than the needs we originally assumed were there.
We also discovered how important it is to use research to create nursing interventions that will
actually be successful. Our research guided us towards interventions that already had been tested
and proved beneficial. Submitting a proposal to the HPRB was another process we learned more
about. This was a useful skill to learn because we will have to use it when we conduct research in
the future. From HPRB we learned the importance of being concise in our wording, and
developing a survey, and consent forms. By developing a survey we learned to make questions
that were objective and not leading to what we are hoping to find. Through all our learning
Falls Prevention 31
experiences in this project it has become apparent that in order to accomplish our goals it will
take small steps and patience, which takes time.
As a group we acquired better communication skills than we had previously. We realized
that it was important to be direct with each other and make sure that our voices were heard, yet
also be willing to listen. When we had differing opinions we made an effort to understand each
other‟s perspective and come to a consensus. We came up with strategies to meet each other‟s
needs, to keep our group on task, and function effectively as a team (timeline, goals, agendas,
deadlines, etc). For the purpose of the paper we learned how to meld all of our voices into one
view point so that the paper would flow smoothly rather than be chaotic and difficult to follow.
Working in a group forced us to be flexible and work around each other‟s schedules because we
had to rely on each other in order to accomplish our goals.
If we were to do this project all over again there are several things that we would do
differently, as well as attempt to improve upon things that we feel that we already do fairly well.
Regarding the survey, we would create more uniform interviews and questions for all
participants. We would come in with an open-mind rather than assume that we already knew
what the problem was. If we had more time we would survey the patients to get their input on
the problem, make the copies of all the brochures and signs ourselves, ask for financial
assistance for signs and brochures, and complete the implementation process by actually going
and physically placing the signs in the patient‟s rooms and handing out the brochures to the
nursing staff ourselves.
Although we have gained skills and knowledge through working on this project there are
still skills that we can acquire and improve upon. We are continually improving our critical
Falls Prevention 32
thinking skills by staying up to date on research and evaluating all options at hand. To acquire
leadership skills we will challenge ourselves by putting ourselves into leadership positions and
practicing leadership theories we have learned throughout the semester. Examples of how we
will challenge ourselves include, putting ourselves into public speaking situations and continuing
our education on the topic.
In addition to developing our leadership skills we recognize that followership skills are
equally important to the functioning of a group. We can develop these skills by allowing others
to be in control, by stepping back, working on listening to others, and building off of other‟s
ideas. All of these help establish trust in the leader and other group members. Overall this has
been a significant learning process for all our group members.
This project was a great learning experience for all of us. It grew and refined our
assessment and surveying skills, it challenged us to use leadership theories to work as an
effective group, and it encouraged us to look within our community and see what we could
improve. We used the nursing process which consists of assessment, diagnosis, planning,
implementation, and evaluation to achieve quality improvement by decreasing falls and
concurrently cost at Linden Grove. We are confident that the improvement that we have initiated
will have positive effects on the lives of the patients and staff at Linden Grove, as well as the
Falls Prevention 33
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