Falls are a major health problem in older adults and they are the 6th leading cause of death among Canada’s elder population. By definitions, falls are incidents which results in an individual being forced to involuntarily rest on a lower level of ground which is in most cases the floor. The Canadian Nurses Association (2005) reveals that falling accounts for 84 percent of inpatient incidents and it makes up 75 percent of all injuries in patients aged 75 and above. Rapp et al. (2008) state that residents of long term care facilities are predisposed to falling with up to 50% of residents being involved in falls every year. Of the percentage that falls, 10% to 25% require hospital treatment for the injuries sustained from the falls. This is significant considering that falls are a major health problem since they result in complications such as; fractures, head injuries, and post-fall anxiety. Falls and fall-related complications correlate to higher morbidity and mortality in the long term care setting. The monetary cost of falls is significant bearing in mind that the Canadian government spends more than $980 million on treating falls among the elderly (Canadian Nurses Association, 2005). Research indicates that over $138 million could be saved annually if preventive strategies were put in place. In addition to this, falls have the ability to undermine the quality of the nurse-patient relationship since the patients’ perceive that the nurse should know their fall risk and hence prevent it from happening.
Falls and their outcomes may result in functional deterioration, personal suffering, caregiver burden, and increased medical costs for the patient. It is therefore imperative that steps be undertaken to decrease the frequency of falls or eliminate them all together. The public has made significant investments in fall prevention due to the realization that falling imposes a significant social and financial burden on the community. These investments have culminated in the formulation of prevention programs aimed at ensuring safety of dwellers in long term care facilities. This paper will set out to discuss a number of nursing interventions that can be implemented to address the issue of falls.
Risk Factors for Falls
Before delving into preventive strategies, it is important to review the risk factors for falls in the long term care setting. Whitaker (2011) broadly classifies risk factors leading to falls into two categories; extrinsic (environmental factor and often mechanical) and intrinsic (from within the patient). Common extrinsic factors include; reduced lighting conditions, wet floor, ill-fitting or unsuitable footwear, stairs without handrails, uneven or changes in floor surfaces (textures and levels), and inappropriate furniture height to name but a few.
Intrinsic risk factors are more diverse and they include a number of common conditions which are outlined below.
- A History of falls predisposes an individual to more falling in future with research showing that a person who has fallen in the past has a 50% likelihood of falling again (Fitzgerald, et al., 2009).
- Age more than 70
- Previous use of assisted device
- Heavy alcohol beverage
- Conditions that impaired balance or gait such as stroke, Parkinson’s disease, dementia, epilepsy, Meniere’s disease etc.
- Patients with impaired mobility in case of chronic disorders like osteoporosis, low blood pressure, diabetes, arthritis, heart diseases, nutritional disorders and malnutrition etc.
- Patients with cognitive impairment e.g. dementia, delirium, Alzheimer disease
- Medication errors or adverse effect of drugs e.g. sedative, antihistamine, oral hypoglycemic agent, diuretic, antihypertensive
- Bladder dysfunction such as urgency, incontinence, nocturnal voiding
- Psychiatric illness
- Any defect of vision e.g. cataract, macular degeneration, glaucoma
As demonstrated above, falls can be caused by a myriad of reasons which makes some incidents of falling unavoidable. Even so, the administering of proper care to high risk group can have a positive impact.
Implementation of Preventive Program for Falls
Prevention of falls is a desirable objective for both the patient and the health care providers. Preventive programs promise to achieve significant reductions in falls. For a preventive program for falls to succeed, it needs to be based on best and recommended practices. Best practice guidelines such as preventive processes can only be effectively executed, provided there are suitable plans, proper resource utilization along with administrative provision, and facilitation.
Nursing Best Practice Guideline
A review of various research efforts on fall prevention highlights the following recommended procedures:
Assessment: Risk assessment by the nurse is identified as a significant strategy for knowing the patient is safe. Through assessment, nurses can evaluate and note which patients are at risk more than others. Identifying the patients who are at risk of fall is regarded by many researchers to be a key component of fall prevention (Whitaker, 2011; Fitzgerald, et al., 2009; Elley, et al., 2008; Wolfgang & Tom, 2007). Assessment will help to determine who falls under the potential risk group of fall prevention program. The tools used to assess individuals are significantly accurate and the sensitivity and specificity of the assessment tool to predict fall is more than 70%. Rush (2009) states that risk assessment should be a regular ongoing process since the risk factor of a patient can change with change in mental status or medication regimen.
Intervention: An intervention is a vital part of the prevention program and its implementation results in the reduction or ultimate elimination of falls. An intervention (to be included in program) is advised on length of stay of patient, if the stay is less than four months then prospect are not enrolled for the program. There are a number of nursing interventions that can be implemented to prevent falling.
Exercise: Customized exercise programs are deemed to be an integral part of fall prevention. The American Geriatrics Society (2011) states that individual and group exercises can be used to strengthen muscles, increase flexibility and improve gait. Lack of exercise will have a negative impact on any fall prevention program. Research by Fitzgerald, Thomas and Ying (2009) shows that activity restriction which is often developed as a result of fear of falling paradoxically increases the likelihood of the long term care resident sustaining a fall since reduced activity can result in muscle atrophy and poor balance. Recommended exercise types include; balance exercises, strength training, tai chi, and cardiovascular, endurance, and fitness training (American Geriatrics Society, 2011). Exercise is not recommended as a standalone intervention but should be part of a multi-factorial intervention program for falls. In addition to this, introduction of exercise programs should be done cautiously since exercising may have adverse effects in persons who were previously unaccustomed to physical activities.
Minimization of Medications: Whitaker (2011, p.52) declares that “medications have consistently been associated with increased risk of falls in the long term care setting”. Evidence supports the notion that withdrawal of psychotropic medication as a form of intervention reduces the risk of falls. Considering this, nurses after consultation with the team should review medication of the patient to see how it can be adjusted so as to prevent falls. Medication adjustments can help reduce the number of falls. A study by Rapp et al. (2008) showed that withdrawal of sedating psychotropic medication in combination with exercise reduced the number of falls by up to 30%. Whitaker (2011) notes that reduction of psychotropic medication as a single intervention has been found to “reduce fall rate while the adjustment or discontinuation of medical regiments as part of a multifactorial intervention has also been found to be effective in reducing falls”.
Educating Clients: Provision of education and information is mandatory for an effective fall prevention program. American Geriatrics Society (2011) asserts that both the patient and the caregivers should be educated on fall prevention strategies. The patients should be made aware of prevention resources that they have at their disposal and specific actions that they can take to build fall prevention skills. Patients who are identified as having increased risks for falls should be advised on how to minimize the risks. Individuals who are undergoing transitions due to medical procedures or muscle weaknesses should be taught how to seamlessly transit and adapt to the new realities. The residents of the long term care facility should be educated on the causes of their falls and made aware of the risks. Evidence suggests that older people who have a good understanding of the reasons behind their falls are more likely to adopt strategies to mitigate future falls (Whitaker, 2011).
Treating Vision Impairment: Old age is in many cases accompanied by a change in visual acuity and “a development of conditions such as cataracts, glaucoma and macular degeneration which reduce the person’s vision” (American Geriatrics Society, 2011, p.151). This conditions increase the risk of falling due to poor vision. Research demonstrates that correction of vision in older people dwelling in long term care facilities reduces risk of falling (American Geriatrics Society, 2011). Nurses should therefore formally access any vision problems or concerns raised by patients. All remedial visual abnormalities should subsequently be treated to ensure that the patient has the best possible vision.
Vitamin D Supplementation: Many older people exhibit impaired muscle strengths and possibly neuromuscular functions. This is as a result of Vitamin D deficiency which is common in older people. Vitamin D supplementation is therefore effective in fall prevention since it helps restore muscle strength as well as bone health. Studies indicate that vitamin D supplementation has benefits even in older persons who have a normal level of vitamin D serum and the supplements are safe to use. This combined with the fact that vitamin D supplements are inexpensive has led to researchers advocating that the supplements be routinely offered to reduce fall risk (Rush, et al. 2009). However, vitamin D supplements should not be used as a stand alone intervention since the administration of vitamin D may not be sufficient to offset the muscular degeneration that older people experience (Rapp, et al., 2008).
Environment: Environmental assessment is a key component in fall prevention. Environmental hazards should be assessed using a check list and measures undertaken to ensure that the hazards are removed (Rapp, et al., 2008). The parameters suggest that nurses must take in modification of environment. Inspecting the surrounding places for wet areas, improper illumination, chairs with armrests, marking with photos, signs or pictures on the doors, and consideration of alarm can minimize the risk of falls.
Nursing Education: Nurses are arguably the healthcare professionals who are affected the most by falls since they work on the frontlines of patient care (Rush et al., 2009). The syllabus for nursing should include teaching on the preclusion of fall injuries and on-going teaching with precise consideration on:
- Promotion of harmless mobility
- Assessment of risk
- Multidisciplinary approaches
- Risk managing including after fall follow-ups
- Substitutes to restraints
Policies and Operating procedures: Organizations should launch a corporate strategy which should at a minimum address the limitation which comprises workings of physical and chemical restraints.
Support of Organization: Organizations should generate an atmosphere that supports interventions for prevention of falls. Key components for the creation of such an atmosphere are:
- Falls deterrence programs;
- Staff instructions;
- Clinical session for risk calculation and mediation;
- Involving multidisciplinary crews in case supervision; and
- Accessibility of deliveries and equipment like transfer devices, high low beds, and bed exit alarms.
RNAO (Registered Nurses Association of Ontario) Toolkit: The best practice strategies of nursing can be efficaciously executed when there is availability of suitable planning, assets, support of administration and proper facilitation. Organizations might hope to improve a strategy for execution including:
- Assessing administrative eagerness and obstacles for education.
- Involving all associates (whether direct or indirect) who add to the execution mode.
- Commitment of competent individual in order to provide the provision which is required for education & carrying out process.
- Continued prospects to discuss and educate to emphasize the significance of finest practices.
- Prospects for reflection on individual and structural capability to implement strategies.
The recommendation made are for managing the employment of the RNAO guideline Prevention of Falls and Fall Injuries in the Older Adult. We apply the above guideline to improve outcomes which involve the frequency of falls, the number of clients sustain a fall, and the number of injuries resulting from the falls.
Strategies of Implementation
- The RNAO (Registered Nurses’ Association of Ontario) and the guideline improvement board have formulated some plans in order to support healthcare organizations to implement these strategies.
- To have on board a radical practicing nurse who provides provision, medical proficiency and leadership and who possesses good interactive, enabling and project supervision skills.
- The initiative should be led by a directing body including significant stakeholders and members in order to have a work design and to track happenings, errands and timelines.
- To formulate and distribute promotional material which will educate and create awareness in the involved stakeholders.
- Organizations employing these guidelines should also engage in; group learning, mentorship and strengthening policies which over time shape the awareness and poise of nurses.
- Elley (2008) recommends the use of an individualized, multifactorial approach so as to increase the chances of success of the fall prevention strategies employed. Nurses are also the professionals who are best suited to select individualized interventions for patients due to their intimate knowledge of the patient’s uniqueness.
Potential Barriers to Success
Like every other issue, there are some barriers towards implementation of the fall prevention program. This is natural and may be because tendency or say human nature of not accepting changes easily. But the real threat is not in having an additional burden of work but is to neglect the right thing. The benefit for program cannot be reaped as a single entity but will be benefiting the community as whole, however, the awareness program conducted for staff, patients, and their families should negate the risk to overcome such barriers in roadmap towards a successful fall prevention program.
If the intervention procedure in place is complicated, the nurses will not be able to effectively adopt it. Rapp, et al. (2008) demonstrate that risk reduction protocols that are inherently complex, requiring changes in interaction patterns between charge nurses and physicians and between charge nurses and the patients reduce the effectiveness of the interventions adopted.
Implications for Nursing
There is an immense need of leaders like the nurse administrators to encourage nurses to implement and promote the fall prevention program. The changed perception of nurses will help the dwellers in long term care settings (and their families) to minimize the risk towards highly prone group. The awards will boost the evidence based health care practice arena and finally the nursing fraternity.
Most falls result from multiple risk factors, and multifactorial interventions are required for positive outcomes to be observed (Elley, 2008). Whitaker (2011) notes that multi-component management plans are the strategies that are most frequently used in long-term care settings. This is because these multifactorial strategies have been proven to result in significant reduction in the number of falls.
Nurses need to engage in constant monitoring so as to ensure the success of fall prevention strategies. Through monitoring, nurses are apprised of the ongoing changes in the patient’s safety levels. Rush et al. (2009) states that vigilant monitoring can be adopted for high fall risk patients with favorable results being achieved. In addition to monitoring of the patient, environmental monitoring can be undertaken to determine the threats to safety that exist in the patient’s environment. Apparatus such as cords and tubing that might contribute to falls are identified and put in a safe place.
Falling is prevalent in long term care settings, and the consequence of falls can be severe. Numerous researches have determined that there are some key risk factors for falling, many of which can be corrected to reduce risk. Fall prevention has been a major goal for the health care community but its achievement has been hampered due to the lack of integrity in implementing prevention programs. Nurses need to look at the patient holistically so as to identify all risks and subsequently provide a safer, risk free environment. Applying ‘Nursing Best Practices Guideline’ with its recommendations will result in a paradigm shift which will certainly have positive implications in nursing practices. Multifaceted intervention have been found to be the most effective means of preventing falls since they consider a wide range of risk factors. An effective program can therefore be achieved by applying multi-factorial prevention strategies which will result in reduction in number of fallers.
American Geriatrics Society (2011). Summary of the Updated American Geriatrics Society/British Geriatrics Society Clinical Practice Guideline for Prevention of Falls in Older Persons. Journal of the American Geriatrics Society, 59(1), 148-157.
Canadian Nurses Association (2005). The built environment, injury prevention and nursing: A summary of the issues. Ottawa: Canadian Nurses Association.
Elley, C.R. et al. (2008). Effectiveness of a Falls-and-Fracture Nurse Coordinator to Reduce Falls: A Randomized, Controlled Trial of At-Risk Older Adults. Journal of the American Geriatrics Society, 56(8), 1383-1389.
Fitzgerald, D.G., Thomas, H., & Ying, C.M. (2009). Caregiver Fear of Falling and Functional Ability among Seniors Residing in Long-Term Care Facilities. Gerontology, 55(4), 460-467.
Rapp, K. et al. (2008). Prevention of Falls in Nursing Homes: Subgroup Analyses of a Randomized Fall Prevention Trial. Journal of the American Geriatrics Society, 56(6), 1092-1097.
Rush, K.L. et al. (2009). Patient falls: acute care nurses’ experiences. Journal of Clinical Nursing, 18(3), 357-365.
Whitaker, D.J. (2011). Preventing falls in older people: assessment and interventions. Nursing Standard, 25(52), 50-55.