NEW YORK NURSE: September 2009
by Barbara Krainovich-Miller, EDD, RN, PMHCNS-BC, ANEF, Assistant Dean, Academic Initiatives, Program Coordinator, Nursing Education Master's and Post MS Certificate Programs, New York University College of Nursing
Despite an enormous amount of research resulting in well-known fall risk assessment tools, falls remain a very serious concern for the healthcare profession and in particular for nursing, as the Joint Commission uses them “as a standard metric of nursing care quality” (p. 299).
Dykes, Carroll, Hurley, Benoit and Middleton (2009) conducted a thorough literature review on falls, soliciting the opinions of RNs and nursing assistants (NA) from four hospitals of one hospital system. The researchers concluded that there was a gap between why falls occur in the acute care hospital setting and what can be done to prevent them. Of the hospitals interviewed, two were academic centers in an urban setting and two were teaching sites in a suburban setting. Nursing leadership identified potential participants.
The study, recently published in June 2009, reported the results of eight group interviews (23 RNs and 19 NAs). The methodology used in the group interviews consisted of a structure guide and clarification questions. Interview data was transcribed, reviewed for accuracy, de-identified, and entered into the NVivo program. Consensus approach coding, data interpretation via content, debriefing among researchers, and reflection were used to determine concept results.
Results revealed six concepts that had “both negative [barriers] and positive [facilitators] components: (1) patient report, (2) information access, (3) signage, (4) environment, (5) teamwork, and (6) involving patient/family with two core categories: knowledge/communication and capability/actions”(p. 301).
The researchers concluded that two components must exist if falls are to be prevented. First an accurate nursing care plan (NCP) based on a fall risk assessment must be developed and accessible to all (i.e., members of the health team, the patient, family and significant others) and second, the health team members must use the plan combined with clinical knowledge, skills and hospital resources so the plan may be utilized by all “stakeholders” (p.304).
This research reinforces the importance of RNs using the nursing process to derive a realistic and easily accessible NCP for all patients, but in particular, those at risk for falls. The nursing assessment for this potential population must include the use of a valid and reliable fall risk assessment tool and diagnostic reasoning skills of the RN to draw an appropriate risk nursing diagnosis (NDx) that would capture the risk status and an appropriate plan (outcome and realistic and tailored nursing interventions) to address the diagnosis. The NCP must be available to all who are involved with the patient: NAs, RNs, physicians, family and significant others and most certainly, the patient themselves. Second, the researchers’ conclusions stress the importance of healthcare team members not only using the NCP, but imply that it must be from an evidence-based practice (EBP) framework (i.e., using their “own knowledge, skills and patient and hospital resources” (p. 299).
From an EBP perspective, the clinician usually views with caution the results of a single qualitative or even quantitative study, unless the results are from a large well conducted meta-analysis on the hierarchy of evidence. The researchers, although they did not explicate the limitations or strengths of their study, made clear the process they used to conduct the study, their funding source, and did not attempt to generalize their findings. However, given that this study used members of the health team who spend the most time with patients (RNs and NAs), as well as the paucity of research that included RNs and NAs, the efforts of these researchers should be applauded. It is the best available evidence at this time that suggests the importance of a realistic NCP and outlines challenges for administrators and educators. The challenge for administrators is to examine current fall risk policies to make sure they provide specific support and resources so as to include Dykes et al.’s predictive model of “inclusion of all stakeholders” (p. 304). The challenge for both hospital and academic nurse educators, in their respective settings, is to teach the nursing process from an EBP perspective (Krainovich-Miller & Haber, 2006; Krainovich-Miller, Haber, Yost, & Jacobs, 2009.) and motivate nurses to formulate NDx as part of the NCP and share it with stakeholders; as well as to reinforce the critical role NYSNA played in changing New York State’s legal definition of nursing in 1972, leading the state to become the first to recognize nursing as an independent profession that makes NDx, rather than simply carries out physician’s orders (NYSNA 2009).
Dykes, P. C., Carroll, D. L., Hurley, A. C., Benoit, A., & Middleton, B. (2009). Why do patients in acute care hospitals fall? Can falls be prevented? The Journal of Nursing Administration, 39(6), 299-304.
Krainovich-Miller, B., & Haber, J. (2006). Transforming graduate curriculum: Jumping the hurdles. In R. Levin, & H. Feldman (Eds.). Teaching and learning evidence-based practice in nursing: A guide for educators. (p. 165-192). NY: Springer.
Krainovich-Miller, B., Haber, J., Yost, J., & Jacobs, S. K. (2009). Evidence-based practice challenge: Teaching critical appraisal of systematic reviews and clinical practice guidelines to graduate students. Journal of Nursing Education. 48(4), 186-95. New York State Nurses Association. (Retrieved, July 24, 2009). Promoting Nursing Legislation. www.nysna.org/ce/academy/module1.htm