Hospital fall-prevention policies may stress nurses, harm patients

By Lorraine L. Janeczko

NEW YORK (Reuters Health) - Hospital policies to prevent patient falls may have unintended negative consequences for nurses and patients, new research suggests.

"When a patient is identified as a fall risk, a strong message comes from supervisors or hospital administrators that the hospital's goal is 'zero falls,' and supervisors put significant pressure on staff nurses to make sure there are no falls," said Dr. Barbara King of the University of Wisconsin-Madison, who worked on the study.

"These messages come frequently and are typically 'blame and shame' in tone," she told Reuters Health by phone. "So the best way for the nurses to protect themselves from blame and shame and to protect their unit from being identified as bad is to just restrict patient mobility. It's not about protecting the patients, it's about protecting themselves, to stop the message."

Falls in older adult hospital patients are common and dangerous, and the Center for Medicare and Medicaid (CMS) has identified falls as a "never event." Many hospitals have set "zero falls" goals and have made the nursing staff responsible for making sure their patients don't fall, Dr. King and her colleagues note in The Gerontologist, online December 23.

The researchers interviewed 27 registered nurses and certified nursing assistants working in two Wisconsin teaching hospitals. Both had nurse-to-patient ratios of 1:4. The first site had 530 beds and a third of patient bed days were used by adults over 65; the second site's capacity was 81 beds with more than half of patient bed days used by adults over 65.

The team held 30- to 60-minute one-on-one interviews with 22 participants and a focus group with five participants, asking open-ended questions about various aspects of taking care of older patients identified as fall risks.

All participants stated that their institution's goal was "zero falls." Many nurses were frustrated by the definition of fall - "any occurrence in which the patient descends to the floor" - because even intentionally lowering a patient to the floor to prevent injury was counted against them.

Nurses who worked on inpatient adult units with high fall rates described intense pressure through frequent messages from senior- and mid-level nursing administrators to "get the number down." The more intense the message, the more the nurses said they restricted patient mobility.

However, nurses who worked on units with low fall rates didn't feel pressured to avoid falls. And they worked with patients to get them walking whether or not they were considered at risk for falls.

"As hospital administration attempted to militarize the approach to reaching zero falls, nurses responded by restricting patients' mobility, likely leading to patient deconditioning - loss of muscle mass, increased frailty - and more falls," said Dr. Peter M. Abadir, an associate professor of medicine in the division of geriatric medicine and gerontology at the Johns Hopkins University School of Medicine in Baltimore, Maryland.

"One of the major obstacles in health care is the silo mentality where nurses, therapists, and clinicians operate as separate teams," he told Reuters Health by email. "The clear message from this paper is that you will not reach the goal of zero falls by making it solely the responsibility of nursing."

"Combined with hard data (the actual number of falls in response to each intervention, etc.) this study is going to be an important tool to help decide how to prevent falls in the hospital setting," added Dr. Abadir, who was not involved in the research.

Dr. King recommends that administrators change their tone and their messages.

"What surprised me was the tenor of the messages the nurses were receiving from their administrators - of blame and shame - that even when they did all the right things to protect their patient, it was their fault that the patient fell," she said.

"The more concerning issue is that there actually isn't any evidence that the 'never event' goal has any impact on fall prevention. In fact, we really don't have much research on how to best prevent falls in hospitals. So we restrict everything the nurses do, restrict their judgment, and make them afraid without giving them the tools they need to actually prevent falls," Dr. King said.

"'Zero falls' is the wrong message," Dr. King emphasized. "We hope this study will open the eyes of administrators about what they should be messaging and how their messaging impacts nurses at the bedside in ways that may be detrimental to their patients."

Dr. Stephen Ferrara, assistant professor of nursing and associate dean of clinical affairs at Columbia University School of Nursing in New York City, said the study "offers an important nursing perspective on patient falls in acute care settings."

"Unreasonable expectations may be placed on the nursing staff for fall prevention when it truly is every member of the health care team's responsibility," Dr. Ferrara, who also was not part of the study, told Reuters Health by email.

SOURCE: https://bit.ly/2iy5wr3

Gerontologist 2016.