Perceptions and Knowledge of Patients and Care Providers: Recommendations for Prevention of Injurious Falls

Transcription

1 Sigma Theta Tau International Honor Society of Nursing 44 th Biennial Convention October 29, 2017 Perceptions and Knowledge of Patients and Care Providers: Recommendations for Prevention of Injurious Falls Lynne Zajac PhD, RN Northern Kentucky University Chris Silka MSN, RN Director of Staff Development and Risk Management Flower Hospital Barb Conover MSN, RN Director of Quality and Accreditation Flower Hospital Deb Vargo PhD, RN (posthumously) Dean College of Nursing & Health Madonna University

2 Background: Clinical-Academic Partnership Call for collaborative initiatives to improve patient outcomes (AACN- AONE, 2012; IOM, 2010). Our partnership: faculty from academia, health care leaders, and graduate students. Meet a need for a mid- west health care system experiencing an increase in fall rates. Promote a patient safety initiative (QSEN, 2017; TJC, 2016; AHRQ, 2017). FALL RESEARCH STUDY 2017 SSTI CONFERENCE 2

3 Problem Inpatient Falls Billions of healthcare dollars spent related to falls (CDC, 2015). Unassisted falls have the potential to cause the greatest injury (Skaggs, Mion & Shoor, 2014). Despite all the regulatory requirements, processes, and tools that are available, falls continue to occur on a daily basis (Dempsey, 2009; Fortinsky, et al., 2004; Hughes et al., 2008; Skaggs, Mion, & Shoor, 2014; Tzeng, H.M, 2011). Need to capture how both patient and nursing knowledge and perception of barriers together may affect patient falls. FALL RESEARCH STUDY 2017 SSTI CONFERENCE 3

4 Relevant Literature Evidence based interventions specific to the patient can be effective by using a team approach (Godlock, Christianson, Feider, 2016). Care processes and fall intervention tools to help reduce the rate of falls in the acute care setting is extensive (Dempsey, 2008 & 2009, Tzeng et. al, 2011, 2013, 2015; Wilson et al., 2016;Yardley et al.,2006). While fall risk assessment tools are beneficial, specific interventions that are individualized to the patient s risk may decrease the incidence of injurious falls (Barker, 2014). Model to include patients as active contributors to fall prevention plans (Tzeng & Yin, 2015). FALL RESEARCH STUDY 2017 SSTI CONFERENCE 4

5 Study Purpose: Identify what patient factors influence nurses decisions about hospitalized patients fall risk for injury. Identify factors that influence the patient s perspective of their own risk for experiencing a fall or injurious fall. Identify barriers recognized by the nurses and patients to prevent a fall. FALL RESEARCH STUDY 2017 SSTI CONFERENCE 5

6 Research Questions 1. What are the staff perceptions of the patient being at risk for injurious falls? 2. What are the staff and patient perceived barriers to preventing injurious falls in the hospital setting? 3. Does the knowledge of heightened risk for injury cause implementation of fall precautions? FALL RESEARCH STUDY 2017 SSTI CONFERENCE 6

7 DESIGN MIXED METHOD Factorial Survey with Vignettes One on One Patient Interviews RN & Caregiver Focus groups Setting: Four hospitals in rural and urban settings in the Midwest IRB approval granted from study site and university Pilot Study 150 vignettes FALL RESEARCH STUDY 2017 SSTI CONFERENCE 7

8 Design - Instruments 1. Factorial survey computer generated randomized vignettes. 2. Patient Interview tool - Older Adults Perceptions of Fall Prevention (Miller 2010) [with permission]. 3. Focus group interview tool - Researcher created questionnaire. FALL RESEARCH STUDY 2017 SSTI CONFERENCE 8

9 Survey/Vignettes FACTORIAL SURVEY FALL RESEARCH STUDY 2017 SSTI CONFERENCE 9

10 Part A of Survey Last Case Qualitative section of the survey Asked nurses to recall the last time a patient fell who was under their care. 26 out of the 93 nurses reported no falls. Nurses described similar patient characteristics in their patient fall experiences. FALL RESEARCH STUDY 2017 SSTI CONFERENCE 10

11 Part B of the Survey Part B of each survey contains six unique, randomly generated vignettes, including a control. Each scenario includes a combination of six variables. Likert scale-rn assessment of the scenario about: 1) the patient s risk for a fall 2) a risk for fall with an injury, and 3) likelihood to initiate a fall risk strategy. FALL RESEARCH STUDY 2017 SSTI CONFERENCE 11

12 Vignettes using six independent variables [AHRQ Guideline NGC-9096] Independent variables Levels Age (6 levels) 45,55,65,75,85,95 Medical Problem (5 levels) Cognition (3 levels) Fall History (2 levels) Medications (8 levels) Mobility Fluid and electrolyte imbalance, urinary frequency, abdominal surgery, bleeding disorder, orthopedic surgery Agitated, alert and oriented, confused History, no history Antidepressant, benzodiazepine, digoxin, sedative/hypnotic, multiple meds, no meds, opiate, diuretic Ambulates with a cane, ambulates with a walker, bedfast, ambulates with help, needs no help ambulating FALL RESEARCH STUDY 2017 SSTI CONFERENCE 12

13 Sample Vignette The patient is 65 years old and admitted to the nursing unit for orthopedic surgery. The patient is alert and oriented, has a history of falls, and is currently on a sedative/hypnotic. The patient identifies the need to use the bathroom. The chart indicates the patient ambulates with help. FALL RESEARCH STUDY 2017 SSTI CONFERENCE 13

14 Part C of Survey Demographic information on RN participants: 465 surveys were distributed to nurses in 4 urban and rural hospitals in the Midwest. 93 surveys were returned (20%) with 558 vignettes completed. Degrees held: AAS(28); Diploma(5); BSN(52); BS(1); MSN(5); MS(2) Practice sites: Medical/Surgical Units and ICUs Shift:7AM -7 PM (44); 7PM-7AM(44); 7AM-3PM(3); 2 other FALL RESEARCH STUDY 2017 SSTI CONFERENCE 14

15 Question 1: What is the perceived risk for this patient falling? 0-No risk Significant variables to nurses p <.05 Age = (p=.000); ANOVA Age 65 (p=.026) History of a fall (p=.000) Mobility (p=.030) ANOVA not significant Cognition confused (p=.002) Diagnosis- Urinary frequency (p=.061) 10-Highest Risk Medications-(p=.006) digoxin; sedative/hypnotic; multiple meds; opiate; diuretic FALL RESEARCH STUDY 2017 SSTI CONFERENCE 15

16 Question 2: What is the perceived risk for this patient to experience an injury if they fell? 0-No injury 10-Highest risk for injury Age- (p=.000); ANOVA; Age 65 and 75 Meds- ANOVA; multiple meds and opiates History of a fall-(p=.009) Medical problem-(p=.000) ANOVA; Urinary frequency, bleeding disorder and orthopedic surgery Cognition-(p=.016) ANOVA; agitated and confused FALL RESEARCH STUDY 2017 SSTI CONFERENCE 16

17 Question 3: How likely would you be to implement a fall risk strategy for this patient? 0-not likely 10-very likely Age- (p=.000) History of Fall- (p=.000) Meds ANOVA; antidepressants; benzodiazepines; digoxin; sedatives/hypnotics; opiates FALL RESEARCH STUDY 2017 SSTI CONFERENCE 17

18 General Discussion Cognition was significant in nurses perceptions of fall risks and injuries related to falls, however cognition was not factor in the nurses likelihood to implement fall risk interventions. FALL RESEARCH STUDY 2017 SSTI CONFERENCE 18

19 Focus Groups and Patient Interviews FALL RESEARCH STUDY 2017 SSTI CONFERENCE 19

20 Focus Groups & Interviews Focus Groups 3-5 people per group 4 RN groups; 1 NA group; 1 mixed group Open ended questions- patient fall risk, barriers to prevention 20 RNs, 4 NAs Patient interviews One- on- one interviews 30 minutes each 25 patients from each hospital; 75 total interviews. Patient perceptions about falls, fall risk and prevention Data analysis identify common phrases; constant comparative analysis FALL RESEARCH STUDY 2017 SSTI CONFERENCE 20

21 Focus Group Questionnaire Developed by the researchers Asked participants to consider the most recent fall event that you were involved in. Open ended questions about how the fall occurred interventions that were in place the barriers that interfered with preventing the fall actions by others including health care providers and hospital leadership opinions about resources and why falls occur despite risk assessment and prevention FALL RESEARCH STUDY 2017 SSTI CONFERENCE 21

22 General Discussion: Focus Groups 1. Contributing factors to falls noted by RNs & NAs Medications Changes in medications, mental status, physical condition of patient Room environment issues Patient did not request assistance Patients still fall with interventions in place 2. Barriers to fall prevention noted by RNs Patient room too far from nurses station; Lack of follow through with established interventions Lack of communication between health care workers Lack of staffing, lack of available sitters 3. Need for additional or enhanced Interventions More frequent re/assessment Educate and communicate so that patients understand their risk Use judgement over and above existing data FALL RESEARCH STUDY 2017 SSTI CONFERENCE 22

23 4 Themes Focus Groups Themes Environmental Issues Contribute to Falls Communication/Education Needed to Prevent Falls Change in Patient Condition Requires Action Lack of Staffing and Staffing Patterns Contribute to Falls Statements I believe that transferring a patient in the middle of the night from a neuro floor to our floor kind of made him a little more combative and we could have gone around that better. Could have transferred him at a different part of the day that would have been better for his cognitive status at that point. I am not sure we are using those key words that this is to keep you safe so it may not be sinking in to the patient. I mean they are not interpreting the things that we are doing as safety measures. I think sometimes you can t go by the Morse Fall Risk Assessment, If you really have it in your gut that they should be on a bed alarm, put them on a bed alarm. I think that we all, when we do our initial assessment in the beginning, the fall prevention protocols are all in place. You check everything but as the day goes on and things get busier, it is harder to keep track of all of that. FALL RESEARCH STUDY 2017 SSTI CONFERENCE 23

24 Quote to Sum It Up People are out of their element when they are here. It s not their home, things aren t where they think they should be, we need to especially at night, keep anything clutter, things out of the way that will make them trip or fall, education for staff, education for the patient and of course family, but you do all that and you are still going to have falls but maybe not as many you just do your best. - RN FALL RESEARCH STUDY 2017 SSTI CONFERENCE 24

25 One-on-One Interviews - Demographics Demographic N= 75 Age years 26 Age years 49 Male 22 Female 53 Hx of Falls No 15 Hx of Falls Yes 1 Fall 29 Hx of Falls Yes 2 or more Falls 27 Hx of Falls no response 4 Injury yes 25 Injury no 27 Injury no response 23 Total 75 FALL RESEARCH STUDY 2017 SSTI CONFERENCE 25

26 One-on-one Patient Interview Questionnaire Older Adults Perceptions of Fall Prevention (Miller 2010) 75 patients; English speaking, over age 60 years, alert and oriented 7 opened ended questions: Fall history Knowledge of falls Fall risk Prevention actions Need for more information FALL RESEARCH STUDY 2017 SSTI CONFERENCE 26

27 General Discussion: One-on-One Patient Interviews Patients : report education via TV commercials. report advice about falling from family members. unsure of their risk even in the presence of a risk bracelet or a fall risk sign. have ideas about decreasing risk about the home environment. majority report a history of multiple falls mostly at home. associate injurious falls with broken bones hips and knees. FALL RESEARCH STUDY 2017 SSTI CONFERENCE 27

28 Themes Knowledge of the Potential for Falls through Education Lifestyle Alterations with Advancing Age Fall Risk Denial/Ambivalence Despite Education 3 Themes patient Quotes No throw rugs, no cords around, A night light ; I read about it year old lives at home, no falls [haven't learned] uh, not so much prevention of falling. But more of, uh, the rescue of someone falling. With, uh, the Life Alert and all that stuff. I live alone. I have one of those things that you wear around your neck and press a button. -73 female has fallen at home I just don t do some of the things I used to do - 79 year old male fell twice at home at home When asked if a healthcare provider spoke to them about falling after discussing the Call Don t Fall sign in the patient s room: no not really just that sign Interviewer do you think its helpful? Patient yeah, I think. Interviewer do you try to do anything so you don't fall? Patient Yeah I ll hold onto something. 69 year old female with history of falls at home FALL RESEARCH STUDY 2017 SSTI CONFERENCE 28

29 Quote to Sum It Up 80 year old female oh there is always something on TV about falling. Oh you see stuff in magazines, but I usually don t pay attention to it. I haven t [fallen] except once when I was in the rehab center and I wasn t supposed to get up by myself, but I called twice and nobody came and I had to go to the bathroom so I got up and took my walker and went to the bathroom. And was getting up to leave the bathroom and I just quietly slid right down on the floor. I mean I really didn t really fall, I didn t hurt.. No, I wasn t injured at all. FALL RESEARCH STUDY 2017 SSTI CONFERENCE 29

30 Recommendations FALL RESEARCH STUDY 2017 SSTI CONFERENCE 30

31 Recommendation #1 1. Evaluate use of current fall risk assessment tool. Add critical thinking component to fall risk assessment tool to individualize care. Add a tool to identify risk for injury. Scale the level of risk. More frequent fall risk assessments. A change in diagnosis, addition of a new medication should trigger additional assessment. Add best practice alerts for additional fall risk assessments to current electronic health record. FALL RESEARCH STUDY 2017 SSTI CONFERENCE 31

32 Recommendation #2 2. Reframe patient education. Change the verbiage to be specific to the individual patient needs. Be clear to the patient about what a fall risk indicates. Engage the patient and family in the fall risk plan. Encourage teach back of concepts presented to patient. FALL RESEARCH STUDY 2017 SSTI CONFERENCE 32

33 Recommendation #3 3. Reinforce education of nurses. Include concepts listed in recommendations #1 and #2. Provide patient scenarios that indicate a change in fall risk level. A change in fall risk level indicates a need for additional or different interventions. Stress the need to include patient input in the plan of care. FALL RESEARCH STUDY 2017 SSTI CONFERENCE 33

34 Limitations in the Study Low response rate on the survey. Less units available due to changes in the health care organization. Responses of focus groups may be unique to the practice setting. FALL RESEARCH STUDY 2017 SSTI CONFERENCE 34

35 Implications of the Study Provides opportunity to develop a comprehensive plan for the health care organization which may: prevent or remove barriers related to falls and fall risks. decrease injuries related to falls. impact patient outcomes and decrease healthcare costs long term. FALL RESEARCH STUDY 2017 SSTI CONFERENCE 35

36 Thank- you Flower Hospital Foundation Zeta Theta Chapter at Large Sigma Theta Tau Dr. Brain Fink - Statistician Patients, RNs, NAs who gave voice to the study Graduate Students: Martha Guyton, Natalie Jones, Tom Voyles Ginger Martindale Marisol Strelow Lourdes University Madonna University Northern Kentucky University FALL RESEARCH STUDY 2017 SSTI CONFERENCE 36

37 References Agency for Healthcare Research and Quality. (2017). Quality and patient safety programs. Retrieved from American Organization of Nurse Executives. (2012). Guiding principles: AACN-AONE task force on academicpractice partnerships. Retrieved from partnerships.pdf Barker, W. (2014). Assessment and prevention of falls in older people. Nursing Older People, 26(6), Center for Disease Control and Prevention. (2015). Cost of falls among older adults. Retrieved from Dempsey, J. (2008). Risk assessment and fall prevention: Practice development action. Contemporary Nurse, 29, (2), Dempsey, N. (2009). Nurse values, attitudes and behavior related to falls prevention. Journal of Clinical Nursing, 18, doi:10.111/j x Fortinsky, R., Iannuzzi-Sucich, M., Baker, D., Gottschalk, M., King, M., Brown, C., & Tinetti, M. (2004). Fall-risk assessment and management in clinical practice: views from healthcare providers. JAGS, 52, (9), FALL RESEARCH STUDY 2017 SSTI CONFERENCE 37

38 Godlock, G., Christianson, M., & Feider, L. (2016). Implementation of an evidence-based patient safety team to prevent falls in inpatient medical unit. MedSurg Nursing, 25(1), Haines, T. & McPhail, S. (2011). Threat appraisal for harm from falls: Insights for development of education -based intervention. Open Longevity Science, 5, Hughes, K., van Beurden, E., Eakin, E., Barnett., L, Patterson, E., Blackhouse, J., Newman, B. (2008). Older person s perception of risk of falling: Implications for fall prevention campaigns. American Journal of Public Health, 98(20), The Institute of Medicine. (2010). The future of nursing: leading change, advancing health. The National Academies Press: Washington, D.C. Miller, C. (2010). Older adults perceptions of fall prevention education: A qualitative study. (Master s thesis, Western Carolina University). Retrieved from: Quality and Education Safety for Nurses. (2017). Graduate QSEN competencies-safety. Retrieved from Staggs, V., Mion, L. & Shorr, R. (2014). Assisted and unassisted falls: different events, different outcomes, different implications for quality of hospital care. Jt Comm J Qual Patient Saf, 40(8) FALL RESEARCH STUDY 2017 SSTI CONFERENCE 38

39 Tzeng, H-M. (2011). Triangulating the extrinsic factors for inpatient falls from the fall incident reports and nurse s and patient s perspectives. Applied Nursing Research, 24, Tzeng, H-M. (2015) Patient engagement in hospital fall preventions. Nursing Economics, 33(6), Tzeng, H-M. & Yin, C-Y. (2013). Frequently observed factors for fall-related injuries and effective preventive interventions: A multihospital survey of nurses perceptions. J Nurs Care Qual, 28(2), doi /ncq.ob013e The Joint Commission. (2015). National patient safety goals Retrieved from Wilson, D., Montie, M., Conlon, P., Reynolds, M., Ripley, R., & Titler, M. (2016) Nurses perceptions of implementing fall prevention interventions to mitigate patient-specific fall risk factors. Western Journal of Nursing Research, 38(8), doi: / Yardley, K, Donovan-Hall, M, & Todd, C. (2006). Older people s views of advice about falls prevention: A qualitative study. Health Education Research Theory & Practice, 21(4), FALL RESEARCH STUDY 2017 SSTI CONFERENCE 39

40 Questions? Or for more information: Lynne Zajac FALL RESEARCH STUDY 2017 SSTI CONFERENCE 40