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					                                                                      Falls Prevention   1


        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 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

older adults.

       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

               prevention education.

                  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
                                                                               Falls Prevention     21

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

       Linden Grove.

       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 (

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

facility itself.
                                                                             Falls Prevention     33


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