The Nurse's Role in Fall Prevention: Identifying Risks and Implementing Safety Precautions

In our senior population, fall injuries are the number one cause of accidental death. The fatality rate and number of injuries reported from falls are continually rising in this age group (Centers for Disease Control and Prevention, 2006).

Because accidental fall injuries are the primary cause of mortality, morbidity, and suffering among people over the age of 65, it is the nurse’s responsibility to identify older people at high risk, implement safety practices in the healthcare setting and community, and to educate patients, caregivers, and coworkers in order to reduce the occurrence of accidental falls. Todd & Skelton (2004) states, “Health and social care agencies need to work together to prioritize fall prevention as part of their overall strategy for promoting healthy ageing” (para.6). It is the nurse’s role to initiate these strategies.
Falls among older adults is an enormous public health problem. Falls are associated with major morbidity, functional decline and increased healthcare costs (Centers for Disease Control and Prevention, 2006). Fall related injuries impact the older adult in both pain and suffering, and the loss of independent function. Eliopoulos (2005) states, “Even if no physical injury occurs, fall victims may develop a fear of falling again (eg., postfall syndrome) and reduce their activities as a result; this can lead to unnecessary dependency, loss of function, decreased socialization, and poor quality of life” (p.269). With the senior population steadily increasing, it is a nursing priority to use preventative measures to reduce the occurrence of fall injuries.
Nurses need a systematic way to identify who is at risk of falling and utilize preventative measures to make the healthcare environment safer for the patient. According to Fletcher, Fankhauser, Lee, & Westley (2004), “previous studies indicate that the use of a risk factor approach to assess older people can prevent more than 50% of falls” (para 10). During the initial patient assessment at a healthcare establishment, a fall assessment tool needs to be utilized. A fall assessment tool should be objective and systematic. The most important features of a fall assessment tool are: it is easy to use, quick to complete, reliable at identifying an at-risk person, and most importantly - used consistently (Fletcher, Fankhauser, Lee, & Westley, 2004). Nurses need to be involved to examine the effectiveness of the fall assessment tool and to educate fellow nurses if it is not being used when indicated. Along with identifying high risk patients, nurses need to implement safety practices in healthcare facilities and should encourage the use of outpatient fall prevention programs.
Nurses need to have the authority to modify the physical environment as they see fit to increase patient safety. Major hazards contributing to falls in the healthcare setting are the use of physical restraints and slippery floors. Nearly 50% of falls at healthcare facilities have been found to be bed-related with the use of bedrails (Fletcher, Fankhauser, Lee, & Westley, 2004). Instead of using restraints, the nurse should have the option of placing the high risk patient’s bed at floor level. Another option is utilizing bed alarms, which alerts the nurse’s station when a patient is out of bed. To address slippery floors, nurses should encourage the use of non-slip footwear, anti-skid floor wax, non-skid rugs, skid-proof strips near the bed, and having a bedside commode available for patients who urinate frequently. If these are not being implemented, nurses need to address these issues to management. The healthcare setting is not the only place where fall prevention can be addressed. The nurse should look to the community as well.
Nurses needs to initiate and/or encourage utilization of fall prevention programs in the community. Studies have proven that high risk seniors participating in fall prevention programs, focusing on strength exercises, have a significant decrease in amount of accidental falls (Diener & Mitchell, 2005). An important factor for the nurse to consider when implementing a program is structuring it to promote continuity for the high risk participants. Utilizing community centers and adult day health centers that integrate a fall prevention program with their structured activities is a way to ensure that individualized interventions are incorporated into the client’s everyday care. Also, the nurse should be a resource in the community to help promote a safer environment. For example, the nurse can participate in city committees to advocate for keeping the streets and sidewalks well lit and in good repair (Todd & Skelton, 2004). A key factor to retaining a person’s independence is having the nurse lead them to the proper resources needed and provide education that is useful to that individual.
The nurse has an important role in evaluating and educating patients, caregivers, and co-workers on strategies to reduce fall accidents. Individualized interventions can be planned when the nurse has direct contact with the patients and their caregivers during routine doctor visits. Encouraging home assessments can find hazards in the home, environmental and behavioral, to be identified and corrected with appropriate referral and advice. The nurse can also educate co-workers about certain factors that contribute to a person’s risk of falling while staying in a healthcare setting. A person’s physical condition, medication use, length of stay at the hospital, time of day, and the number of nursing staff available are all factors contributing to fall injuries. According to Dowling & Kelly (2005), staff education and awareness programs, implemented by nurses, can be effective in reducing falls by 50% in healthcare facilities.
The elderly are a rapidly growing percentage of the population, and are increasingly at risk of falling and consequent injuries. Because accidental fall injuries are the primary cause of mortality, morbidity, and suffering among people over the age of 65, it is the nurse’s responsibility to identify older people at high risk, know the contributing risk factors, implement safety practices in the healthcare setting and community, and to educate patients, caregivers, and coworkers in order to reduce the occurrence of accidental falls. Nurses can make a difference by promoting awareness so co-workers and patients can make the safest choices possible to prevent falls. By utilizing these key strategies, the nurse can help in reducing the amount of preventable injuries that occur in our elderly population.

References:

Diener, D., & Mitchell, J. (2005). Impact of multicultural fall prevention program upon falls of older frail adults attending an adult day health center. Topics in Geriatric Rehabilitation, 21, 247-258. Retrieved on October 28, 2006, from Expanded Academic ASAP database.

Dowling, M., & Kelly, A. (2004). Reducing the likelihood of falls in older people. Nursing Standard, 18, 33-40. Retrieved October 18, 2006, from Expanded Academic ASAP database.

Eliopoulos, C. (2005). Gerontological nursing. (Q. McDonald, Ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

Fletcher, K., Fankhauser, K., Lee, V., & Westley, C. (2004). Competent to care: Strategies to assist staff in caring for elders. MedSurg Nursing, 13, 281-289. Retrieved October 18, 2006, from Expanded Academic ASAP database.

Todd, C., & Skelton, D. (2004, March). What are the main risk factors for falls amongst older people and what are the most effective interventions to prevent these falls? Retrieved October 29, 2006 from http://www.euro.who.int/document/E82552.pdf
Centers for Disease Control and Prevention. (2006). Trend in health and aging. Retrieved April 10, 2006 from http://www.cdc.gov/nchs/agingact.htm

Intervention 1: Nurses need to initiate and/or encourage utilization of fall prevention programs in the community. Studies have proven that high risk seniors participating in fall prevention programs, focusing on strength exercises, have a significant decrease in amount of accidental falls (Diener & Mitchell, 2005). Community centers and adult day health care are settings where frail older adults are likely to benefit from fall reduction programs.

Disadvantage 1: There are many adult day health center programs available, but all have varying curriculums. A high risk senior attending one of these programs is not a guarantee that fall prevention strategies will be addressed. An important fall prevention intervention calls for specific exercises at a consistent interval with proper education to reverse high risk behaviors. In order for exercise programs to be effective in this setting, it must be longer than a 10 week interval and led by an appropriately qualified professional (Todd & Skelton, 2004). Studies have proven that benefits from exercise programs, targeted at high risk seniors, start decreasing by 6 months if the exercises are not being done on a regular basis (Diener & Mitchell, 2005).

Disadvantage 2: Seniors on a limited financial income may not be able to afford these programs. Many seniors are dependant on social security for their only source of income and Medicare may not pay for the fall prevention programs available. The cost of adult day health programs vary. According to the Robert Wood Johnson Foundation, from the article: A new lifeline for older people, “The cost averages about $56 a day for adult day health care and Medicare does not pay for these programs, so participants generally pay out of pocket.” Seniors on a fixed income, who couldn’t afford the additional expense, would be excluded out of these types of programs.

Intervention 2: The nurse has an important role in evaluating and educating patients on fall prevention. Individualized interventions can be planned when the nurse has direct contact with the patients and their caregivers during routine doctor visits. It also gives an opportunity for the nurse to provide information in areas the client needs improvement on concerning high risk behaviors or environment surroundings.

Disadvantage 1: During an office visit, the nurse can run into several obstacles that may prevent client teaching. When the client is sick or debilitated, their main focus is the issue that brought them into the clinic. The patient’s readiness to learn may be diminished. In order for the teaching to be effective, the nurse must quickly assess: expectations, learning needs, motivation to learn, ability to learn, teaching environment, and resources for learning (Perry & Potter, 2005). If these items are not addressed, the teaching will be ineffective. For example, there is no motivation to learn if the client is high risk but doesn’t think the prevention strategies are important or pertain to them. Also, an illness or disease can effect the client’s motivation and/or ability to learn. Resources to help facilitate the teaching environment and reinforce the information may not always be available to the nurse. For example, the nurse may not be able to find out the available resources in the clients home that would help with fall prevention. In some cases, the client may require the support of family and the nurse must assess the readiness and ability of the family to learn the information and implement interventions (Perry & Potter, 2005). If the family is not at the client’s appointment, this assessment by the nurse cannot be preformed.

Disadvantage 2: There is still considerable debate on which individuals should be targeted for fall prevention strategies, and how quickly to intervene. The nurse has discretion on who may qualify for these interventions in a clinic setting. According to Todd & Skeleton (2004), target populations should include older people who seek medical attention for a fall, repeat fall victims, older people discharged from the hospital, institutionalized or homebound, those experiencing gait problems, and those with previous fragility fracture and risk factors for osteoporosis. The nurse should examine personal biases when determining client needs for individualized risk assessment and interventions. In all settings, clear lines of responsibility, clear policies aimed at managing falls, procedures for all professional groups involved, and a referral network need to work together (Todd & Skelton, 2004). Primary care settings may need to implement a screening procedure to improve the screening rates of those at risk and to reduce human bias in the selection process.

References:

A new lifeline for older people. (2007, June). Work & Family Life, 21-6 Retrieved on October 26, 2007, from Expanded Academic ASAP database.

Diener, D., & Mitchell, J. (2005). Impact of multicultural fall prevention program upon falls of older frail adults attending an adult day health center. Topics in Geriatric Rehabilitation, 21, 247-258. Retrieved on October 28, 2006, from Expanded Academic ASAP database.

Perry, A.G., & Potter, P.A. (2005). Fundamentals of Nursing. St. Louis, Missouri: Elsevier Mosby.

Todd, C., & Skelton, D. (2004, March). What are the main risk factors for falls amongst older people and what are the most effective interventions to prevent these falls? Retrieved October 29, 2006 from http://www.euro.who.int/document/E82552.pdf