Two categories were identified that explained why participants in this study fell: the need to toilet coupled with loss of balance and unexpected weakness. No participant suffered an injury requiring treatment or a longer length of hospital stay. Participants identified strategies that they believed would enhance fall prevention during an acute care hospitalization.
3.1. Reasons for falling
The loss of balance in the context of an urgent need to reach the bathroom was identified as the most common reason for falling. Participants described their pressing need to use the bathroom that clouded their memory of their physical limitations and prevented them from taking the time to attain physical balance. One participant described his known low blood pressure early in the morning. At home, he usually would sit on the side of his bed before standing, but while in the hospital, his urge for the bathroom and the use of a sleeping medication 6 hours earlier fogged his memory:
I think I just had to go, so I stood up. I got very dizzy… and then my whole body went numb….I just reached for the floor and landed on my hip.
After being transferred from another facility for management of a stroke, a participant needed to get to the bathroom. Focused on the bathroom need and not on the reason for being hospitalized, he stood up and described falling as, “I crumbled like a piece of paper.”
Other participants described being involved in an activity that they had never had a problem performing previously. A participant, on her sixth or seventh lap of an ambulation schedule which she had performed daily, fell on her 47th day of hospitalization.
In fact, I just lost my footing. I cannot describe it any other way…it could have been…the soles of my shoes…it could have been that I just brushed by something or it could have been the neuropathy….
Additional reasons given for their falls included not getting enough physical therapy and not having necessary items within reach (in this case, the brace she needed was not in reach when she needed to get to the bathroom). Another participant stated that he rang for help a number of times, but when no one came, he attempted to get to the bathroom on his own.
3.2. Patient activities to reduce falls
When asked what they could do to prevent themselves from falling, participants identified the need to be involved in their own activity assessment by asking themselves, “Before I get up, I need to think.” Taking the time to stop and think allowed participants to be more thoughtful about their abilities. Pausing reduced a hurrying manner, carelessness, and denial about the risk of falling. Some participants stated that they did not think that they would be as weak as they were, whereas others “forgot” about their deficits because of illness and surgery.
I was trying to get the photo album to show pictures, and for some reason, when I got to the edge of the bed, I thought I still had my leg. So, I went to put pressure on my leg, and there was nothing. I am not used to it being amputated.
Participants did note the request from their nurses to call them before they get out of the bed and the chair or go to the bathroom. “I am supposed to call for help…but I don’t want to bother them [the nurses].” One participant was provided her call light but on the side where she had weakness, so she was unable to put her call light on when she needed assistance. Another participant stated,
Luckily, I was close enough to the bed to reach my call light…it [call light] didn’t slip away as it usually does in the night, it slips down, you know, and then I can’t reach it.
Most participants expressed the emotional obstacle of not calling for assistance because they did not want to be a bother to the nurse. The physical obstacle of actually having a device to call for assistance and being able to wait for a person responding to their need for assistance were also deterrents to their fall prevention.
Most participants mentioned that they were not aware of their risk of falling, and those who were told of their risk received inconsistent messages regarding their risk from different nurses. Participants wanted to be informed and told of why they were at risk and what specific activities the nurse wanted them to do to reduce their risk and the role of the health care team in their fall prevention.
Participants recognized that having an appropriate assistive device and safe footwear is important for fall prevention. A number of participants had been admitted urgently and did not have their walkers with them. This required the health care provider to request one for use during hospitalization.
I use a walker at home…to get to the bathroom. The nurses want me to use the commode, but I prefer going to the bathroom because it is giving me extra exercise.
Three participants used hospital slippers because of the gripper material on the bottom, whereas another who had been hospitalized for a significant length of time sought expert option on appropriate footwear from a physical therapist. Clear paths to the bathroom and better lighting were mentioned as changes to the hospital environment to improve fall prevention.
3.3. Nursing activities to reduce falls
A clear message from participants in this study is their need to feel that asking for assistance with getting up out of bed, walking, and going to the bathroom or into a chair is not bothering the nurse. Four participants mentioned that they were told to call for help. Nurses should emphasize that calling for help is not bothering them. It is not a question of whether or not patients can get out of bed by themselves; it is the nurses’ work to keep patients safe. Patients need to know that not only does the nurse not mind coming to help them, even if they are busy, but also that the nurse wants to come and help. Helping patients is a priority for the nurse whether or not they appear to be busy. No patient should ever feel the same as one participant said, “I feel like I called the nurse enough. You know I don’t want to be a bother.”
3.4. Implications for nursing practice
The major reasons for falling from the patients’ perspective are the need to toilet coupled with loss of balance and unexpected weakness; both reasons appear amenable to nursing interventions to prevent falls, although patients believed that some of these falls were not preventable. Because patients expressed reluctance to call for help from the nurse because they thought the nurses appeared too busy, the message has to be given to, heard by, and acted upon by patients and their families. All nurses need to share and deliver a clear and consistent message that they are there for patients and to provide a safe environment, including providing prompt responses to meet patient needs.
A comprehensive assessment of the patient’s history of falls (six of nine participants in this study had previously fallen) should be the first step on the continuum of communication of fall risk (Morse, 1997
). Other areas to assess are comorbidities, gait, mental status, and need for (as well as availability of) ambulatory aids. A plan of care can be generated from this assessment that is tailored to specific nursing interventions to overcome explicit fall risks. The plan then needs to be communicated to nursing assistants and all members of the multidisciplinary health care team, and a clear message from the patients is to include the patient and their family in this communication. A successful communication of this plan at the point of care is a pivotal part of a nurse-led fall prevention program.