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Older, in hospital and confused – The value of nursing care in preventing falls in older people with cognitive impairment
International Journal of Nursing Studies 52 (2015) 1285–1287
Contents lists available at ScienceDirect
International Journal of Nursing Studies journal homepage: www.elsevier.com/ijns
Guest Editorial
Older, in hospital and confused – The value of nursing care in preventing falls in older people with cognitive impairment
Falls and injury from falls are internationally recognised as an important health and safety matter for hospitals today and an indicator of the quality of nursing care (ANA, 2012; Burston et al., 2014). In the United States, the prevalence of in-hospital falls in a study of 315,817 falls over a 27 month period was 3.56 falls/1000 patient days, with 26.1% of these falls resulting in an injury (Bouldin et al., 2013). In England and Wales, over 280,000 hospital falls are reported each year (NPSA, 2010). And, in one Australian report, 10% of patient days for people over the age of 65 years were attributable to falls injury, reflecting 1.4 million patient days over the year, a doubling from 0.7 million in ten years earlier (AIHW, 2013). Falls are rarely evenly distributed across units. In a longitudinal study of 8915 nursing units in the United States, the falls rates per 1000 patient days varied widely over several years (He et al., 2012). For example in 2008, it varied from 1.32 (0.95) in critical care units, to 4.32 (2.64) in medical units, to 7.06 (3.61) in rehabilitation units (He et al., 2012). Fall rates are also much higher in older people with cognitive impairment, with 68% of in-hospital falls attributed to this group (Hill et al., 2007). Other research confirms that the prevalence of falls for people with cognitive impairment is significantly higher than for those at the same age without cognitive impairment (Harlein et al., 2011). In fact, in one American study, 96% of 252 patients who fell during their hospital stay were diagnosed with delirium at the time of the fall (Lakatos et al., 2009). Significantly, nurses report that this high risk group is the most challenging group with whom to implement falls prevention (Barker, 2012). Falls can have a number of significant adverse consequences, especially for vulnerable groups. When an older person experiences an adverse event, such as an inhospital fall, it can quickly lead to an irreversible decline in functional status (Thornlow et al., 2009; Chu et al., 2007), often delaying discharge home. Other adverse outcomes from falls include fractures, head injuries, other minor injuries such as bruises and abrasions, reduced mobility or http://dx.doi.org/10.1016/j.ijnurstu.2015.02.003 0020-7489/ß 2015 Elsevier Ltd. All rights reserved.
limitations to activities, loss of independence, and need for nursing home placement (Terroso et al., 2014). Given its high rate of occurrence, and significant consequences to patient, families and the health system, prevention is an international priority. For example, in Australia, falls prevention is one of the ten Australian National Safety and Quality Health Service Standards that are used to accredit hospitals (ACSQHC, 2011). There is general agreement that a combination of falls risk assessment and multifactorial interventions should be used to reduce the incidence of in-hospital falls (Cameron et al., 2012; DiBardino et al., 2012). Specific interventions to prevent in-hospital falls include early risk assessment using a validated instrument (Ivziku et al., 2011), followed by exercise (supervised/unsupervised), medication management, urinary incontinence management, fluid or nutrition therapy, psychosocial support and assistive technology, including personal mobility aids and anti-slip footwear, communication aids such as glasses and hearing aid, and education, including provision of written materials, videos, lectures (ProFaNE, 2007; NICE, 2013). There is agreement that multiple care interventions are required to address the various factors that contribute to falls (NICE, 2013). Strategically, these care interventions can be bundled. A care bundle is a structured group of interventions that have been shown to improve patient outcomes (IHI, 2013). They are designed to improve processes of care and encourage clinical practice guideline compliance. Various care bundles have been developed for a variety of clinical populations and recently have been developed for patients at risk of falls (Healey et al., 2014; Neyens et al., 2011; Teresi et al., 2013; Milisen et al., 2013), showing some promising results. Like those strategies to prevent falls, the strategies to prevent and manage cognitive impairment in older people while in hospital are also multi-faceted and target early ambulation, assistance with meals, social engagement, and cognitive stimulation (Inouye et al., 2006; ACSQHC, 2014). Nursing care that is focused on adequate nutrition and
1286
Editorial / International Journal of Nursing Studies 52 (2015) 1285–1287
hydration, ambulation, cognitive stimulation, and elimination is essential for older people with cognitive impairment who are at high risk of falling. Attention to essential nursing care is the responsibility of qualified nurses. But, for some older people with cognitive impairment, the system, and in particular nurses’ responses, are failing (Parke and Hunter, 2014). While the vulnerability of older people in hospital is established, nurses do not explicitly acknowledge the risks of injury to older people while in hospital. Older person vulnerability is compounded by a dominant ageist attitude within society in general, and in health care services specifically. Older people are marginalised in hospital (Higgins et al., 2007), with, for example, staff generally accepting that falling is inevitable in older hospitalised people (Walker, 2004). Nurses perceive that older people stay too long and require more nursing time than is available (Parke and Hunter, 2014). For older people with cognitive impairment, the vulnerability is intensified when they exhibit disruptive behaviours, lack of interest in their surroundings, and/or make incoherent noises. Such disruptive behaviours often lead to custodial, rather than nursing, care (Moyle et al., 2010). The valuing of young people over older people in hospital is ubiquitous (Scheunemann and White, 2011). Ageism contributes to increased vulnerability for older people in hospital and this is an urgent problem for the nursing profession. There is emerging evidence that increases in patient acuity and skill mix also have consequences for patient safety (Elnitsky et al., 2014; Duffield et al., 2011), with nurses working in hospitals focusing care on medical treatments, and rationing care to address immediate safety and health concerns rather than the relatively mundane activities of daily living. The rise of health technology means that nurses are increasingly focused on delivering medical treatments and therapies and managing health equipment. This privileging of the medically related care means that tasks associated with medically related care are rarely missed (Schubert et al., 2013) but less ‘technical’, some would say essential, nursing care tasks are consistently missed. Ambulation is one of the most missed nursing care activities (Kalisch et al., 2012; Papastravrou et al., 2014). When ambulation interventions are not attended, accelerated loss of function occurs in older people (Sinha and Detsky, 2012), increasing the risk of falling when ambulant. Privileging medically related tasks over other nursing work, combined with a dominant ageist attitude and difficulty determining care needs, has negative implications for health outcomes of older people with cognitive impairment in hospital. Rather than focus on tasks or interventions, it is timely to remind ourselves of the values and principles of nursing. Person centred nursing care – to work with patient’s beliefs and values, engage patients and families, share decisionmaking, have a sympathetic presence, and provide for physical needs (McCormack and McCance, 2006) – provides a suitable framework for advancing the care of older people with cognitive impairment who are at risk of falling. We propose a low intensity approach to falls
prevention generally, and in older people with cognitive impairment specifically. For us, a low intensity approach is implies both individualised care and a stepped approach to nursing care, with increasing intensity based on patient condition, risk and need. A low intensity approach is focused on essential nursing care. While a low intensity approach has not been explicitly trialled in falls research to our knowledge, the principles of low intensity (individualised and stepped based on increasing interventions as risk increases) are clearly a cornerstone of all professional nursing practice, including falls. In a low intensity approach, essential nursing care, such as ambulation, hydration, nutrition and elimination needs, is tailored to the individual patients’ needs, their values and their preferences; nursing care is person-focused. Greater attention to essential nursing care can prevent the development of delirium (Mudge et al., 2013) and falls and injuries from falls (D’Amour et al., 2014). Essential nursing care is a valuable resource that is absent when nurses ration care to favour medically related treatments. We invite the international nursing community to confront ageism and engage in dialogue to promote the value of essential nursing. Nursing is focused on wellness and aims to promote comfort, function, nutrition, hydration, and elimination. It is time to claim back these essential elements of nursing for the benefit of vulnerable older adults in our hospitals. References Australian Institute of Health & Welfare [AIHW], Bradley, C., 2013. Trends in Hospitalisations Due to Falls by Older People, Australian 1999–1900 to 2010–2011. Injury Research and Statistics No. 84. Cat. No. INJCAT 160 AIHW, Canberra American Nurses Association [ANA], 2012. National Database of Nursing Quality Indicators. Retrieved 30.12.12 from https://www. nursingquality.org/data.aspx. Australian Commission on Safety and Quality in Health Care [ACSQHC], 2011. National Safety and Quality Health Service Standards. ACSQHC, Sydney. Australian Commission on Safety and Quality in Health Care [ACSQHC], 2014. A Better Way to Care: Safe and High-Quality Care for Patients with Cognitive Impairment (Dementia and Delirium) in Hospital – Actions for Health Service Managers. ACSQHC, Sydney. Barker, A., 2012. An evaluation of the preventing falls and harm from falls in older people best practice guidelines for Australian hospitals: insights into quality, implementability. In: Awareness and Uptake of the Key Recommendations in Australian Acute Hospitals. CRE-PS, Monash University, Melbourne. Bouldin, E.L.D., Andresen, E.M., Dunton, N.E., Simon, M., Waters, T.M., et al., 2013. Falls among adult patients hospitalized in the United States: prevalence and trends. J. Patient Saf. 9 (1) 13–17. Burston, S., Chaboyer, W., Gillespie, B., 2014. Nurse-sensitive indicators to reflect nursing care quality: a review and discussion of the issues. J. Clin. Nurs. 23 (13–14) 1785–1795. Cameron, I.D., Gillespie, L.D., Robertson, M.C., Murray, G.R., et al., 2012. Interventions for preventing falls in older people in care facilities and hospitals. Cochrane Database Syst. Rev. 12, CD005465, http:// dx.doi.org/10.1002/14651858.CD005465.pub3. Chu, L., Chi, I., Chiu, A., 2007. Falls and fall-related injuries in communitydwelling elderly persons in Hong Kong: a study on risk factors, functional decline, and health services utilization after falls. Hong Kong Med. J. 13 (Suppl. 1) 8–12. D’Amour, D., Dubois, C., Tchouaket, E., Clarke, S., Blais, R., 2014. The occurrence of adverse events potentially attributable to nursing care in medical units: cross-sectional record review. Int. J. Nurs. Stud. 51, 882–891. DiBardino, D., Cohen, E.R., Didwania, A., 2012. Meta-analysis: multidisciplinary fall prevention strategies in the acute care inpatient population. J. Hosp. Med. 7 (6) 497–503.
Editorial / International Journal of Nursing Studies 52 (2015) 1285–1287 Duffield, C., Diers, D., O’Brien-Pallas, L., Aisbett, C., Roche, M., King, M., Aisbett, K., 2011. Nursing staffing, nursing workload, the work environment and patient outcomes. Appl. Nurs. Res. 24, 244–255. Elnitsky, C.A., Lind, J.D., Rugs, D., Powell-Cope, D., 2014. Implications for patient safety in the use of safe patient handling equipment: a national survey. Int. J. Nurs. Stud. 51, 1624–1633. Harlein, J., Halfens, R.J.G., Dassen, T., Lahmann, N.A., 2011. Falls in older hospital inpatients and the effect of cognitive impairment: a secondary analysis if prevalence studies. J. Clin. Nurs. 20, 174–183. He, J., Dunton, N., Staggs, V., 2012. Unit-level time trends in in-patient fall rates of US hospitals. Med. Care 50 (9) 801–807. Healey, F., Lowe, D., Darowski, A., Windsor, J., et al., 2014. Falls prevention in hospitals and mental health units: an extended evaluation of the FallSafe quality improvement project. Age Ageing 43, 484–491. Higgins, I., Van der Riet, P., Slater, L., Peek, C., 2007. The negative attitudes of nurses towards older people in the acute hospital setting: a qualitative descriptive study. Contemp. Nurse 26, 225–237. Hill, K.D., Vu, M., Walsh, W., 2007. Falls in the acute hospital setting – impact on resource utilisation. Aust. Health Rev. 31 (3) 471–477. Inouye, S., Baker, D.I., Fugal, P., Bradley, E.H., HELP Dissemination Program, 2006. Dissemination of the Hospital Elder Life Program: implementation, adaptation and successes. J. Am. Geriatr. Soc. 54, 1492–1499. Institute for Healthcare Improvement [IHI], 2013. What Is a Bundle? . http://www.ihi.org/knowledge/Pages/ImprovementStories/ WhatIsaBundle.aspx (accessed 28.02.13). Ivziku, D., Matarese, M., Pedone, C., 2011. Predictive validity of the Hendrich fall risk model II in an acute geriatric unit. Int. J. Nurs. Stud. 48, 468–474. Kalisch, B.J., Tschannen, D., Lee, K.H., 2012. Missed nursing care, staffing and patient falls. Nurs. Care Qual. 27 (1) 6–12. Lakatos, B.E., Capasso, V., Mitchell, M.T., Dilroy, S.M., et al., 2009. Falls in the general hospital: association with delirium, advanced age, and specific surgical procedures. Psychosomatics 50 (3) 218–226. McCormack, B., McCance, T.V., 2006. Development of a framework for person-centred nursing. J. Adv. Nurs. 56 (5) 472–479. Milisen, K., Coussement, J., Arnaut, H., Vanlerberghe, V., De Paepe, L., Schoevaerdts, D., et al., 2013. Feasibility of implementing a practice guideline for fall prevention on geriatric wards: a multicentre study. Int. J. Nurs. Stud. 50, 495–507. Moyle, W., Borbasi, S., Wallis, M., Olorenshaw, R., Gracia, N., 2010. Acute care management of older people with dementia: a qualitative perspective. J. Clin. Nurs. 20, 420–428. Mudge, A.M., McRae, P., Cruickshank, M., 2013. Eat, walk engage: an interdisciplinary model to improve care of hospitalized elders. Am. J. Med. Qual., http://dx.doi.org/10.1177/1062860613510965. National Institute for Clinical Excellence [NICE], 2013. Falls: Assessment and Prevention of Falls in Older People. NICE Clinical Guideline 161, In: http://www.nice.org.uk/guidance/cg161. National Patient Safety Agency [NPSA], 2010. Slips, Trips and Falls in Hospital Data Update. NPSA, London. Neyens, J., van Haastregt, J.C., Dijcks, B.P., Martens, M., et al., 2011. Effectiveness and implementation aspects of interventions for
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preventing falls in elderly people in long-term care facilities: a systematic review of RCTs. J. Am. Med. Dir. Assoc. 12, 410–425. Papastravrou, E., Andreou, P., Tsangari, H., Schubert, M., De Geest, S., 2014. Nursing care within professional environmental constraints: a correlational study. Clin. Nurs. Res. 23 (3) 314–335. Parke, B., Hunter, K.F., 2014. The care of older adults in hospital: if its common sense why isn’t it common practice? J. Clin. Nurs. 23, 1573–1582. ProFaNE, 2007. Manual for the Fall Prevention Classification System Downloaded from http://www.profane.eu.org/documents/Falls_Taxonomy. pdf (accessed 25.09.14). Scheunemann, L.P., White, D.B., 2011. The ethics and reality of rationing in medicine. Chest 140 (6) 1625–1632. Schubert, M., Ausserhofer, D., Desmedt, M., Schwendimann, R., et al., 2013. Levels and correlates of implicit rationing of nursing care in Swiss acute care hospitals – a cross-sectional study. Int. J. Nurs. Stud. 50, 230–239. Sinha, S.K., Detsky, A.S., 2012. Measure, promote, and reward mobility to prevent falls in older patients. JAMA 308 (24) 2573–2574. Teresi, J.A., Ramirez, M., Remler, D., Ellis, J., Boratgis, G., et al., 2013. Comparative effectiveness of implementing evidence-based education and best practice in nursing homes: effects on falls, quality-of-life and societal costs. Int. J. Nurs. Stud. 50, 448–463. Terroso, M., Rosa, N., Marques, A.T., Simoes, R., 2014. Physical consequences of falls in the elderly: a literature review from 1995 to 2010. Eur. Rev. Aging Phys. Act. 11 (1) 51–59. Thornlow, D.K., Anderson, R., Oddone, E., 2009. Cascade iatrogenesis: factors leading to the development of adverse events in hospitalised older patients. Int. J. Nurs. Stud. 46, 1528–1535. Walker, W., 2004. Promoting a safe environment for confused older people at risk from falling in hospital. J. Orthop. Nurs. 8, 72–76.
Laurie Grealish Associate Professor Subacute and Aged Nursing, Research Centre for Health Practice Innovation, Griffith Health Institute, Griffith University and Gold Coast Health, Gold Coast, Australia Wendy Chaboyer Professor of Nursing and Director, NHMRC Centre of Research Excellence in Nursing, Research Centre for Health Practice Innovation, Griffith Health Institute, Griffith University, Gold Coast, Australia Received 17 December 2014
Contents lists available at ScienceDirect
International Journal of Nursing Studies journal homepage: www.elsevier.com/ijns
Guest Editorial
Older, in hospital and confused – The value of nursing care in preventing falls in older people with cognitive impairment
Falls and injury from falls are internationally recognised as an important health and safety matter for hospitals today and an indicator of the quality of nursing care (ANA, 2012; Burston et al., 2014). In the United States, the prevalence of in-hospital falls in a study of 315,817 falls over a 27 month period was 3.56 falls/1000 patient days, with 26.1% of these falls resulting in an injury (Bouldin et al., 2013). In England and Wales, over 280,000 hospital falls are reported each year (NPSA, 2010). And, in one Australian report, 10% of patient days for people over the age of 65 years were attributable to falls injury, reflecting 1.4 million patient days over the year, a doubling from 0.7 million in ten years earlier (AIHW, 2013). Falls are rarely evenly distributed across units. In a longitudinal study of 8915 nursing units in the United States, the falls rates per 1000 patient days varied widely over several years (He et al., 2012). For example in 2008, it varied from 1.32 (0.95) in critical care units, to 4.32 (2.64) in medical units, to 7.06 (3.61) in rehabilitation units (He et al., 2012). Fall rates are also much higher in older people with cognitive impairment, with 68% of in-hospital falls attributed to this group (Hill et al., 2007). Other research confirms that the prevalence of falls for people with cognitive impairment is significantly higher than for those at the same age without cognitive impairment (Harlein et al., 2011). In fact, in one American study, 96% of 252 patients who fell during their hospital stay were diagnosed with delirium at the time of the fall (Lakatos et al., 2009). Significantly, nurses report that this high risk group is the most challenging group with whom to implement falls prevention (Barker, 2012). Falls can have a number of significant adverse consequences, especially for vulnerable groups. When an older person experiences an adverse event, such as an inhospital fall, it can quickly lead to an irreversible decline in functional status (Thornlow et al., 2009; Chu et al., 2007), often delaying discharge home. Other adverse outcomes from falls include fractures, head injuries, other minor injuries such as bruises and abrasions, reduced mobility or http://dx.doi.org/10.1016/j.ijnurstu.2015.02.003 0020-7489/ß 2015 Elsevier Ltd. All rights reserved.
limitations to activities, loss of independence, and need for nursing home placement (Terroso et al., 2014). Given its high rate of occurrence, and significant consequences to patient, families and the health system, prevention is an international priority. For example, in Australia, falls prevention is one of the ten Australian National Safety and Quality Health Service Standards that are used to accredit hospitals (ACSQHC, 2011). There is general agreement that a combination of falls risk assessment and multifactorial interventions should be used to reduce the incidence of in-hospital falls (Cameron et al., 2012; DiBardino et al., 2012). Specific interventions to prevent in-hospital falls include early risk assessment using a validated instrument (Ivziku et al., 2011), followed by exercise (supervised/unsupervised), medication management, urinary incontinence management, fluid or nutrition therapy, psychosocial support and assistive technology, including personal mobility aids and anti-slip footwear, communication aids such as glasses and hearing aid, and education, including provision of written materials, videos, lectures (ProFaNE, 2007; NICE, 2013). There is agreement that multiple care interventions are required to address the various factors that contribute to falls (NICE, 2013). Strategically, these care interventions can be bundled. A care bundle is a structured group of interventions that have been shown to improve patient outcomes (IHI, 2013). They are designed to improve processes of care and encourage clinical practice guideline compliance. Various care bundles have been developed for a variety of clinical populations and recently have been developed for patients at risk of falls (Healey et al., 2014; Neyens et al., 2011; Teresi et al., 2013; Milisen et al., 2013), showing some promising results. Like those strategies to prevent falls, the strategies to prevent and manage cognitive impairment in older people while in hospital are also multi-faceted and target early ambulation, assistance with meals, social engagement, and cognitive stimulation (Inouye et al., 2006; ACSQHC, 2014). Nursing care that is focused on adequate nutrition and
1286
Editorial / International Journal of Nursing Studies 52 (2015) 1285–1287
hydration, ambulation, cognitive stimulation, and elimination is essential for older people with cognitive impairment who are at high risk of falling. Attention to essential nursing care is the responsibility of qualified nurses. But, for some older people with cognitive impairment, the system, and in particular nurses’ responses, are failing (Parke and Hunter, 2014). While the vulnerability of older people in hospital is established, nurses do not explicitly acknowledge the risks of injury to older people while in hospital. Older person vulnerability is compounded by a dominant ageist attitude within society in general, and in health care services specifically. Older people are marginalised in hospital (Higgins et al., 2007), with, for example, staff generally accepting that falling is inevitable in older hospitalised people (Walker, 2004). Nurses perceive that older people stay too long and require more nursing time than is available (Parke and Hunter, 2014). For older people with cognitive impairment, the vulnerability is intensified when they exhibit disruptive behaviours, lack of interest in their surroundings, and/or make incoherent noises. Such disruptive behaviours often lead to custodial, rather than nursing, care (Moyle et al., 2010). The valuing of young people over older people in hospital is ubiquitous (Scheunemann and White, 2011). Ageism contributes to increased vulnerability for older people in hospital and this is an urgent problem for the nursing profession. There is emerging evidence that increases in patient acuity and skill mix also have consequences for patient safety (Elnitsky et al., 2014; Duffield et al., 2011), with nurses working in hospitals focusing care on medical treatments, and rationing care to address immediate safety and health concerns rather than the relatively mundane activities of daily living. The rise of health technology means that nurses are increasingly focused on delivering medical treatments and therapies and managing health equipment. This privileging of the medically related care means that tasks associated with medically related care are rarely missed (Schubert et al., 2013) but less ‘technical’, some would say essential, nursing care tasks are consistently missed. Ambulation is one of the most missed nursing care activities (Kalisch et al., 2012; Papastravrou et al., 2014). When ambulation interventions are not attended, accelerated loss of function occurs in older people (Sinha and Detsky, 2012), increasing the risk of falling when ambulant. Privileging medically related tasks over other nursing work, combined with a dominant ageist attitude and difficulty determining care needs, has negative implications for health outcomes of older people with cognitive impairment in hospital. Rather than focus on tasks or interventions, it is timely to remind ourselves of the values and principles of nursing. Person centred nursing care – to work with patient’s beliefs and values, engage patients and families, share decisionmaking, have a sympathetic presence, and provide for physical needs (McCormack and McCance, 2006) – provides a suitable framework for advancing the care of older people with cognitive impairment who are at risk of falling. We propose a low intensity approach to falls
prevention generally, and in older people with cognitive impairment specifically. For us, a low intensity approach is implies both individualised care and a stepped approach to nursing care, with increasing intensity based on patient condition, risk and need. A low intensity approach is focused on essential nursing care. While a low intensity approach has not been explicitly trialled in falls research to our knowledge, the principles of low intensity (individualised and stepped based on increasing interventions as risk increases) are clearly a cornerstone of all professional nursing practice, including falls. In a low intensity approach, essential nursing care, such as ambulation, hydration, nutrition and elimination needs, is tailored to the individual patients’ needs, their values and their preferences; nursing care is person-focused. Greater attention to essential nursing care can prevent the development of delirium (Mudge et al., 2013) and falls and injuries from falls (D’Amour et al., 2014). Essential nursing care is a valuable resource that is absent when nurses ration care to favour medically related treatments. We invite the international nursing community to confront ageism and engage in dialogue to promote the value of essential nursing. Nursing is focused on wellness and aims to promote comfort, function, nutrition, hydration, and elimination. It is time to claim back these essential elements of nursing for the benefit of vulnerable older adults in our hospitals. References Australian Institute of Health & Welfare [AIHW], Bradley, C., 2013. Trends in Hospitalisations Due to Falls by Older People, Australian 1999–1900 to 2010–2011. Injury Research and Statistics No. 84. Cat. No. INJCAT 160 AIHW, Canberra American Nurses Association [ANA], 2012. National Database of Nursing Quality Indicators. Retrieved 30.12.12 from https://www. nursingquality.org/data.aspx. Australian Commission on Safety and Quality in Health Care [ACSQHC], 2011. National Safety and Quality Health Service Standards. ACSQHC, Sydney. Australian Commission on Safety and Quality in Health Care [ACSQHC], 2014. A Better Way to Care: Safe and High-Quality Care for Patients with Cognitive Impairment (Dementia and Delirium) in Hospital – Actions for Health Service Managers. ACSQHC, Sydney. Barker, A., 2012. An evaluation of the preventing falls and harm from falls in older people best practice guidelines for Australian hospitals: insights into quality, implementability. In: Awareness and Uptake of the Key Recommendations in Australian Acute Hospitals. CRE-PS, Monash University, Melbourne. Bouldin, E.L.D., Andresen, E.M., Dunton, N.E., Simon, M., Waters, T.M., et al., 2013. Falls among adult patients hospitalized in the United States: prevalence and trends. J. Patient Saf. 9 (1) 13–17. Burston, S., Chaboyer, W., Gillespie, B., 2014. Nurse-sensitive indicators to reflect nursing care quality: a review and discussion of the issues. J. Clin. Nurs. 23 (13–14) 1785–1795. Cameron, I.D., Gillespie, L.D., Robertson, M.C., Murray, G.R., et al., 2012. Interventions for preventing falls in older people in care facilities and hospitals. Cochrane Database Syst. Rev. 12, CD005465, http:// dx.doi.org/10.1002/14651858.CD005465.pub3. Chu, L., Chi, I., Chiu, A., 2007. Falls and fall-related injuries in communitydwelling elderly persons in Hong Kong: a study on risk factors, functional decline, and health services utilization after falls. Hong Kong Med. J. 13 (Suppl. 1) 8–12. D’Amour, D., Dubois, C., Tchouaket, E., Clarke, S., Blais, R., 2014. The occurrence of adverse events potentially attributable to nursing care in medical units: cross-sectional record review. Int. J. Nurs. Stud. 51, 882–891. DiBardino, D., Cohen, E.R., Didwania, A., 2012. Meta-analysis: multidisciplinary fall prevention strategies in the acute care inpatient population. J. Hosp. Med. 7 (6) 497–503.
Editorial / International Journal of Nursing Studies 52 (2015) 1285–1287 Duffield, C., Diers, D., O’Brien-Pallas, L., Aisbett, C., Roche, M., King, M., Aisbett, K., 2011. Nursing staffing, nursing workload, the work environment and patient outcomes. Appl. Nurs. Res. 24, 244–255. Elnitsky, C.A., Lind, J.D., Rugs, D., Powell-Cope, D., 2014. Implications for patient safety in the use of safe patient handling equipment: a national survey. Int. J. Nurs. Stud. 51, 1624–1633. Harlein, J., Halfens, R.J.G., Dassen, T., Lahmann, N.A., 2011. Falls in older hospital inpatients and the effect of cognitive impairment: a secondary analysis if prevalence studies. J. Clin. Nurs. 20, 174–183. He, J., Dunton, N., Staggs, V., 2012. Unit-level time trends in in-patient fall rates of US hospitals. Med. Care 50 (9) 801–807. Healey, F., Lowe, D., Darowski, A., Windsor, J., et al., 2014. Falls prevention in hospitals and mental health units: an extended evaluation of the FallSafe quality improvement project. Age Ageing 43, 484–491. Higgins, I., Van der Riet, P., Slater, L., Peek, C., 2007. The negative attitudes of nurses towards older people in the acute hospital setting: a qualitative descriptive study. Contemp. Nurse 26, 225–237. Hill, K.D., Vu, M., Walsh, W., 2007. Falls in the acute hospital setting – impact on resource utilisation. Aust. Health Rev. 31 (3) 471–477. Inouye, S., Baker, D.I., Fugal, P., Bradley, E.H., HELP Dissemination Program, 2006. Dissemination of the Hospital Elder Life Program: implementation, adaptation and successes. J. Am. Geriatr. Soc. 54, 1492–1499. Institute for Healthcare Improvement [IHI], 2013. What Is a Bundle? . http://www.ihi.org/knowledge/Pages/ImprovementStories/ WhatIsaBundle.aspx (accessed 28.02.13). Ivziku, D., Matarese, M., Pedone, C., 2011. Predictive validity of the Hendrich fall risk model II in an acute geriatric unit. Int. J. Nurs. Stud. 48, 468–474. Kalisch, B.J., Tschannen, D., Lee, K.H., 2012. Missed nursing care, staffing and patient falls. Nurs. Care Qual. 27 (1) 6–12. Lakatos, B.E., Capasso, V., Mitchell, M.T., Dilroy, S.M., et al., 2009. Falls in the general hospital: association with delirium, advanced age, and specific surgical procedures. Psychosomatics 50 (3) 218–226. McCormack, B., McCance, T.V., 2006. Development of a framework for person-centred nursing. J. Adv. Nurs. 56 (5) 472–479. Milisen, K., Coussement, J., Arnaut, H., Vanlerberghe, V., De Paepe, L., Schoevaerdts, D., et al., 2013. Feasibility of implementing a practice guideline for fall prevention on geriatric wards: a multicentre study. Int. J. Nurs. Stud. 50, 495–507. Moyle, W., Borbasi, S., Wallis, M., Olorenshaw, R., Gracia, N., 2010. Acute care management of older people with dementia: a qualitative perspective. J. Clin. Nurs. 20, 420–428. Mudge, A.M., McRae, P., Cruickshank, M., 2013. Eat, walk engage: an interdisciplinary model to improve care of hospitalized elders. Am. J. Med. Qual., http://dx.doi.org/10.1177/1062860613510965. National Institute for Clinical Excellence [NICE], 2013. Falls: Assessment and Prevention of Falls in Older People. NICE Clinical Guideline 161, In: http://www.nice.org.uk/guidance/cg161. National Patient Safety Agency [NPSA], 2010. Slips, Trips and Falls in Hospital Data Update. NPSA, London. Neyens, J., van Haastregt, J.C., Dijcks, B.P., Martens, M., et al., 2011. Effectiveness and implementation aspects of interventions for
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Laurie Grealish Associate Professor Subacute and Aged Nursing, Research Centre for Health Practice Innovation, Griffith Health Institute, Griffith University and Gold Coast Health, Gold Coast, Australia Wendy Chaboyer Professor of Nursing and Director, NHMRC Centre of Research Excellence in Nursing, Research Centre for Health Practice Innovation, Griffith Health Institute, Griffith University, Gold Coast, Australia Received 17 December 2014