Background

Prevention of falls during hospitalization depends in part on the behaviors of alert patients to prevent falls. Research on acutely ill patients’ intentions to behave in ways that help prevent falls and on the patients’ perceptions related to falls is limited.

Objective

To explore hospitalized adults’ perceptions related to risk for falling, fear of falling, expectations of outcomes of falling, and intention to engage in behaviors to prevent falls.

Methods

Adult, alert, acutely ill inpatients (N = 158) at risk for falling completed a survey consisting of 4 scales and 3 single items. Nurses’ assessments and patients’ perceptions of the risk for falling were compared.

Results

Decreased intentions to engage in behaviors to prevent falls were correlated with patients’ increased confidence in their ability to perform high-risk behaviors without help and without falling (P < .001), decreased fear of falling (P < .001), and decreased perceived likelihood of adverse outcomes if they did fall (P < .001). Although nurses’ assessments indicated a risk for falls, 55.1% of the patients did not perceive a high likelihood of falling while hospitalized. Whereas 75% of patients intended to ask for help before getting out of bed, 48% were confident that they could get out of bed without help and without falling.

Conclusions

Although assessments may indicate a risk for falling, acutely ill inpatients may not perceive they are likely to fall. Patients’ intentions to engage in behaviors to prevent falls vary with the patients’ fall-related perceptions of confidence, outcomes, and fear related to falling.

Falls are the most common adverse event among hospitalized patients, directly contributing to human pain and distress and increased health care costs.19  Complications associated with falls among hospitalized patients can result in death, disability, increased hospital length of stay, placement in an extended care facility, psychological distress, and litigation.1,4,1013  In addition, the cost of falls in the United States may be more than $40 billion by 2020.2,9,14  Researchers have clearly identified factors related to falls1525  and interventions that reduce falls.1,12,1823,2634  Yet, falls continue to be a serious safety threat, especially for acutely ill, hospitalized patients.2,58,16,17,19,20,30,31 

Nurses routinely assess hospitalized patients’ risk for falls and educate patients on preventing falls. However, strategies to reduce falls have limited effectiveness if patients do not follow the fall-prevention plans.15,22,23  Patients may have perceptions about their own risk for falling that influence adherence to fall-prevention plans.3234  Although studies have been done on fall-related perceptions among community-dwelling adults,33,3537  research on fall-related perceptions among acutely ill hospitalized patients is limited. Nurses need new knowledge about why acutely ill patients do or do not engage in behaviors to prevent falls.

Engagement of patients in their own health care is a primary goal of quality and safety initiatives in the United States.15,38,39  Patients no longer are passive recipients of health care, rather they play a vital role in ensuring their own safety. Alert inpatients can partner with the health care team to minimize errors and adverse events. Research4042  supports that nurses are key professionals in engaging patients in the patients’ care. However, few investigations have clarified factors that influence, predict, or shape a patient’s engagement during acute illness. Particularly missing is evidence of the role of the perceptions of acutely ill patients in decision making about behaviors related to safety and to prevention of falls during hospitalization.

The purpose of this study was to explore acutely ill, alert, hospitalized adults’ perceptions related to falls. The 4 aims of the study were as follows:

  1. To explore perceptions that could influence patients’ engagement in behaviors to prevent falls during hospitalization, such as perceived likelihood of falling, fear of falling, perceived expectations of the outcomes of falls, and intention to engage in behaviors to prevent falls

  2. To examine differences between acutely ill patients’ appraisal of the likelihood of falling and nurses’ assessment of the patients’ risk for falling

  3. To identify factors predictive of falls among inpatients during hospitalization for acute illness

  4. To examine psychometric properties of instrumentation used to measure inpatients’ perceptions related to falling

Conceptual Framework

Two theoretical frameworks were used for the study. Protection motivation theory proposes that persons who perceive a health threat may form intentions to take action and avoid harm.43  Factors contributing to threat appraisals include perceived vulnerability to threats, perceived severity of threats, and fear related to threats.4346  Research findings have not yet clarified the proposition that adults may not take action to prevent falls if they do not think they are vulnerable to falling, do not perceive a threat of falling, and are not afraid of falling.

Falls are the most common adverse event among hospitalized patients.

Social cognitive theory proposes that human behaviors are shaped in part by persons’ self-efficacy.47  Efficacy expectations, one component of self-efficacy, are the belief that a person can perform a desired behavior. Outcome expectations, a second component of self-efficacy, are the belief that a behavior will result in a desired effect. If a person is not confident that he or she can perform a behavior or does not think the behavior will create desired outcomes, the person has little incentive to act.

Methods

Design and Setting

A correlational design was used to target a population of adult inpatients in acute care units at Indiana University Health Ball Memorial Hospital, Muncie, Indiana. This 350-bed teaching hospital is part of a state-wide health care system.

Sample

Power analysis48  indicated that a sample size of 150 to 180 patients would have 80% power to detect relationships with a medium- or large-effect size at α = .05. A sample size of 90 patients could be sufficient under ideal conditions; however, intercorrelations among perceptual variables were expected to be high,33  calling for an estimated variance inflation of 2.0.

Patients were included in the convenience sample if they were nonpregnant, English-speaking adult inpatients on an acute care unit; cognitively alert and oriented; assessed by nurses as being at risk for falls (using the assessment tool21  the hospital used at that time); and in stable physiological condition. Exclusion criteria included a medical diagnosis of dementia or delirium and hospitalization in an intensive care unit, extended care unit, obstetric unit, or emergency department. Inpatients hospitalized on acute care units were assumed to be acutely ill.

Falls were incidents in which a patient made an unplanned descent to a lower level.

Measures

The study instrument consisted of a survey of fall-related perceptions, specifically 4 scales and 3 single items. The Confidence to Perform Without Falling Scale (Confidence Scale), developed for this study, was used to measure participants’ perceived confidence that they could perform activities that increased the risk for falling during hospitalization without assistance or falling. The response format was a 5-point Likert scale from 1 (strongly disagree) to 5 (strongly agree). A sample item was While hospitalized, I am confident that I can get out of bed to stand without help and without falling.

The Fear of Falling While Hospitalized Scale (Fear Scale), developed for this study, followed the format of fear-of-falling measures designed for community-dwelling adults.35,37  Degree of concern about falling while performing high-risk activities was measured on a 4-point Likert scale from 1 (not at all concerned) to 4 (very concerned). A sample item was While hospitalized, how concerned are you that you might fall while getting out of a chair without help?

The Consequences of Falling While Hospitalized Scale (Consequences Scale) was used to measure potential adverse outcomes of falling and was adapted from a scale designed for community-dwelling adults.36  The response format was a 4-point Likert scale from 1 (strongly disagree) to 4 (strongly agree). A sample item was If I fall while in the hospital, I will be in pain.

The Intention to Engage in Fall Prevention Scale (Intention Scale), developed for this study, was used to measure participants’ intention to ask for help when performing high-risk behaviors. A sample item was While hospitalized, I intend to ask for help to go to the bathroom. The response format was a 5-point Likert scale 1 (strongly disagree) to 5 (strongly agree).

Three single items were used to measure participants’ perceived likelihood of falling while hospitalized, perceived likelihood of injury if they did fall while hospitalized, and perceived fear of falling. Response formats were 5-point Likert scales from 1 (not at all likely) to 5 (very likely).

All scales and single items were reviewed by a panel of experts on instrument development and safety during critical and acute illness and then were pilot tested. Final revisions resulted in a 38-item survey of fall-related perceptions for acutely ill inpatients.

Three scales developed for community-dwelling adults were also administered as part of data collection, specifically the Falls Efficacy Scale-International,35  the Falls Efficacy Scale,37  and the Consequences of Falling Scale.36  Moderate correlations among scores for community-dwelling and hospitalized adults were anticipated, as evidence of criterion-related validity.

Falls were defined as incidents in which a patient made an unplanned descent to a lower level. Occurrences of falls were recorded by nursing personnel on a report form.

Procedures

After the study was approved by the appropriate institutional review boards, informed consent was obtained from inpatients who met the inclusion criteria, and patients’ fall-risk status was reviewed to verify that the patients were at risk for falls. If a patient’s cognitive alertness was uncertain, the Mini-Cog examination49  and the Confusion Assessment Method50  were used to assess the patient for dementia and delirium. Scores of probably normal and normal, respectively, qualified patients to continue in the study. Participants completed the study instruments by using pen and paper or by verbally responding when the researcher read items verbatim aloud while displaying yellow cards imprinted with large-font response scales. After a patient was discharged from the hospital, the number of falls the patient experienced after enrollment in the study was counted.

Data Analysis

Demographic and clinical variables were analyzed descriptively. Mean scores on multi-item scales were calculated. Instrumentation psychometrics were examined by using principal axis factor analysis, Cronbach α, and Pearson r correlations. Interrelationships and differences among variables were examined by using Pearson r correlations, χ2 test of association, analysis of variance, and t tests. Multiple and logistic regressions were planned to identify perceptual factors predictive of patients who fell. Level of significance was P < .05. Analyses were performed by using SPSS, version 18.0. software (IBM SPSS).

Results

Sample characteristics are displayed in Table 1. Participants (N = 158) were primarily elderly women who had a history of falls in the preceding year. The proportion of participants admitted with cardiopulmonary conditions that required cardiac monitoring and the proportion admitted with orthopedic trauma or for orthopedic surgery were both more than 40%.

Descriptive and Correlational Analysis

Descriptive statistics for study measures are displayed in Table 2. Almost half of the participants (48%) reported being confident or very confident that they could get out of bed without help and without falling, and 81% reported they could reach for items on the bedside table without help and without falling.

The highest mean score on the 4 scales was on the Intention Scale. More than 75% of participants reported they would call for assistance before getting out of bed to walk to the bathroom, walk around in the room, and walk outside the room. However, 10% reported that they would not call for help for any mobility activities. The mean scores of the 3 single items indicated that participants perceived they had a slight likelihood of falling, were somewhat likely to be injured if they fell, and were slightly afraid of falling while hospitalized.

Correlational results are displayed in Table 3 to address the first aim of the study. Significant correlations were found among scores on all 4 scales and single items. Scores on the Fear Scale were most strongly correlated with scores on other scales and items. The activity that raised the most fear was walking outside the hospital room (46%). The most frequently reported anticipated consequences of falling while hospitalized were pain (89%) and difficulty getting up (86%). Participants reported that if they fell, they would still be able to cope alone (69%), be independent (60%), and be active (65%).

Participants’ Characteristics and Fall-Related Perceptions

Data analysis revealed no differences between men and women on total scale scores or single items. Mean scores on the Fear Scale were positively correlated with age in years (r = 0.28; P = .009). Perceived likelihood of falling also increased with age (r = 0.38; P = .04). Furthermore, compared with other participants, participants hospitalized on cardiac progressive care units reported significantly higher perceived likelihood of falling (t = 2.14; P = .03) and higher perceived likelihood of being injured if they fell (t = 2.32; P = .02), yet less fear of falling (t = 3.15; P = .002) and less intention to engage in fall-prevention behaviors (t = 1.98; P = .049).

Data related to the second aim of the study revealed that although assessed by 2 nurses as being at risk for falls, more than half of the participants (n = 87; 55.1%) reported they were not at all likely or were slightly likely to fall during hospitalization. Patients who did not perceive that they were likely to fall anticipated significantly fewer negative outcomes of falling (t = −1.94; P = .05) and less fear of falling (t = −2.67; P = .009) than did patients who perceived that they were likely to fall. Participants who did perceive that they were likely to fall had fallen in the preceding year (χ2 = 14.0; P = .003).

The third aim of the study was to identify perceptions predictive of falls that occurred after enrollment in the study. However, no participants fell after enrollment, despite the statistical projection from hospital databases that 20 patients would fall during the time of data collection. Therefore, the third aim of the study was not addressed.

Psychometric Evaluation of Instruments Used

In order to address the study’s fourth aim, reliability and validity were assessed for all 4 multi-item scales. Internal consistency reliabilities of all scales were high (Table 2). Deletion of any item on any scale would have lowered the reliability. Scores on the adapted Consequences Scale and the newly developed Fear Scale and Confidence Scale were significantly correlated with scores on similar scales developed for nonhospitalized adults,3537  thus supporting criterion-related validity of the new instruments (r = 0.40–0.73; P = .001) Construct validity was examined by using principal axis factor analysis. Single-factor solutions emerged for the Confidence Scale (73% of variance explained; eigenvalue = 5.1), the Intention Scale (59% of variance explained; eigenvalue = 5.3), and the Fear Scale (77% of variance explained; eigenvalue = 5.4). A single-factor solution for the Consequences Scale explained only 29% of the variance, with an eigenvalue of 3.5 and some weak factor loadings. However, because internal consistency reliability was high and intercorrelations with scores on related scales were in an expected direction and magnitude, the Consequences Scale was treated as a single-factor scale.

Discussion

The primary purpose of this study was to explore perceptions that could influence engagement in behaviors to prevent falls during hospitalization among alert, at-risk, acutely ill inpatients. Relative to the study’s first aim, findings reflected that participants with a low intention to engage in fall prevention reported low fear of falling, low perceived likelihood of adverse outcomes from falling, few consequences of falling, and high confidence in safely performing risky behaviors. These findings support the tenets of the protection motivation theory,43  because intention to perform protective health behaviors, such as following fall-prevention plans, was significantly related to perceived vulnerability to a health threat, measured as likelihood of falling; perceived severity of a threat, measured as consequences of falling; and perceived fear of a threat, measured as fear of falling.

Our findings also support the link between self-efficacy and incentive to take action, as set forth in social cognitive theory.47  For example, high efficacy expectations, measured in this study as confidence to perform risky behaviors without falling, were significantly related to intention to follow fall-prevention plans. The relationship was inverse, although conceptually consistent, because the measure of confidence was related to performance of a risk-associated behavior, not a healthy behavior.

Intention to engage does not necessarily mean actual engagement in fall-prevention plans. Acutely ill patients may report an intention to ask for help; however, if help is not quickly available, patients who are confident and unafraid and perceive little likelihood of falling may override their intentions and perform high-risk behaviors.

Our findings suggest that fear of falling is a key perception for nurses to assess in designing fall-prevention plans. Furthermore, fear of falling has been linked to decreased postural control, changes in gait, use of sedatives, and increased falls in numerous studies of community-dwelling adults.31,51,52 

Findings related to the second aim of the study revealed a distinct mismatch between nurses’ and patients’ evaluations of the patients’ risk for falling. Although all participants were assessed by 2 nurses as being at-risk for falling per the hospital’s fall risk assessment tool,21  more than half of the participants did not perceive that they were likely to fall. These findings are similar to those of a recent study52  in which 88% of 193 inpatients did not perceive that they were at risk for falling. In addition, few participants in our study reported being afraid of falling, and few thought they were likely to be injured if they did fall. Furthermore, 10% did not intend to call for assistance when performing any behavior associated with risk for falling.

Surprisingly, no participants fell after enrollment in the study. Because of the mismatch between nurses’ and patients’ assessments of the risk for falls and because no patients fell, could it be that nurses’ assessments were not valid and that participants were not at risk for falling? Perhaps the hospital’s assessment tool did not provide information accurately predictive of patients who might fall. In contrast to earlier reports of the tool’s specificity and sensitivity in hospitalized patients,21  a recent study53  showed that the results of using this tool were not accurately predictive of inpatients who fell.

A competing explanation for the finding that patients did not fall after enrollment in the study is that participants may have experienced a heightened awareness of the danger of falls after completing the survey. Although fall-prevention information was not provided during data collection, fall-prevention messages from the survey may have become encased in a positive nurse-patient relationship, thus increasing the likelihood that participants might have followed fall-prevention plans. Further study is needed to evaluate changes in behavior associated with a risk for falling after a 15- to 30-minute exposure to fall-prevention questions in the context of a nurse-patient relationship.

If help is not available, patients may override their intentions and perform high-risk behaviors.

Our findings have implications for nurses caring for acutely ill patients. Nurses should assess each patient’s risk factors, including fall-related perceptions, and then integrate information on specific risk factors into a fall-prevention plan.5357  Nurses can tailor communication about falls to fit a patient’s perceptions and use the teach-back method to determine how much and how well the patient comprehends and recalls what the nurse told them.56,57  Because research52  suggests that inpatients may not call for help for fear of losing their independence, nurses can emphasize the temporary nature of the activity restrictions. The aim is to create a realistic appraisal of risk without undue anxiety and to provide hospitalized patients with resources and information to make safe decisions.45 

Instrumentation for Fall-Related Perceptions

Currently, the only instruments available to measure fall-related perceptions among inpatients are the scales and items used in this study. Reliability and validity of the Confidence Scale, Fear Scale, and Intention Scale were acceptable but require further evaluation. Revision of the Consequences Scale may be warranted, because all adverse events listed may not have relevance for hospitalized patients. A shortened version of this study’s survey is being tested by the research team for possible usefulness as a clinical tool.

One limitation of our study was the use of a single-site, convenience sample. Second, because of social desirability, patients may have overstated intentions to engage in fall prevention.

We have several recommendations for future research. Studies are needed that do the following: measure actual engagement in behaviors to prevent falls, rather than simply intention to engage; use qualitative methods to identify relevant perceptions beyond those explored in our study; assess the effectiveness of nursing strategies in which fall-prevention education is individually tailored and embedded in a trusting nurse-patient relationship; and test the Schmid21  fall-risk assessment for predictive ability in inpatients. Furthermore, the development of a conceptual framework for engagement in fall-prevention activities could guide research and contribute to the attainment of national patient safety goals.

In conclusion, inpatients’ intentions to engage in behaviors to prevent falls were related to patients’ perceptions of confidence, fear, and likelihood of adverse outcomes from a fall. More than half of the inpatients at risk for falling did not perceive a high likelihood of falling. New strategies are needed to shape the perceptions of patients at risk for falls and to engage acutely ill, alert patients in staying safe during hospitalization.

REFERENCES

REFERENCES
1
Oliver
D
,
Connelly
J
,
Victor
C
, et al
.
Strategies to prevent falls and fractures in hospitals and care homes and effect of cognitive impairment: systematic review and meta-analyses
.
BMJ
.
2006
;
334
(
7584
):
82
.
2
Centers for Disease Control and Prevention, Home and Recreational Safety
.
Falls Among Older Adults: An Overview
. . Accessed June 10, 2015.
3
Tinetti
ME
,
Gordon
C
,
Sogolow
E
,
Lapin
P
,
Bradley
EH
.
Fall-risk evaluation and management: challenges in adopting geriatric care practices
.
Gerontologist
.
2006
;
46
(
6
):
717
725
.
4
Tinetti
ME
,
Mendes de Leon
CF
,
Doucette
JT
,
Baker
DI
.
Fear of falling and fall-related efficacy in relationship to functioning among community-living elders
.
J Gerontol
.
1994
;
49
(
3
):
M140
M147
.
5
Morello
R
,
Barker
A
,
Haines
T
, et al
.
In-hospital falls and fall-related injuries: a protocol for a cost of fall study
.
Inj Prev
.
2013
;
19
(
5
):
363
.
6
Tzeng
H
.
Triangulating the extrinsic risk factors for inpatient falls from the fall incident reports and nurse’s and patient’s perspective
.
Appl Nurs Res
.
2011
;
24
(
3
):
161
170
.
7
Rhalimi
M
,
Helou
R
,
Jaecker
P
.
Medication use and increased risk of falls in hospitalized elderly patients: a retrospective, case-control study
.
Drugs Aging
.
2009
;
26
(
10
):
847
852
.
8
Choi
J
,
Boyle
D
.
RN workgroup job satisfaction and patient falls in acute care hospital units
.
J Nurs Adm
.
2013
;
43
(
11
):
586
591
.
9
Wong
CA
,
Recktenwald
AJ
,
Jones
ML
,
Waterman
BM
,
Bollini
ML
,
Dunagan
WC
.
The cost of serious fall-related injuries at three midwestern hospitals
.
Jt Comm J Qual Patient Saf
.
2011
;
37
(
2
):
81
87
.
10
Coker
E
,
Oliver
D
.
Evaluation of the STRATIFY falls prediction tool on a geriatric unit
.
Outcomes Manag
.
2003
;
7
(
1
):
8
14
.
11
Oliver
D
,
Britton
M
,
Seed
P
,
Martin
FC
,
Hopper
AH
.
Development and evaluation of evidence based risk assessment tool (STRATIFY) to predict which elderly inpatients will fall: case-control and cohort studies
.
BMJ
.
1997
;
315
(
7115
):
1049
1053
.
12
Choi
YS
,
Lawler
E
,
Boenecke
CA
,
Ponatoski
ER
,
Zimring
CM
.
Developing a multi-systemic fall prevention model, incorporating the physical environment, the care process and technology: a systematic review
.
J Adv Nurs
.
2011
;
67
(
12
):
2501
2524
.
13
American Geriatrics Society
.
AGS/BGS clinical practice guideline: prevention of falls in older persons
. . Accessed May 25, 2015.
14
Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Unintentional Injury Prevention
.
Home and recreational safety: cost of falls among older adults
. . Accessed May 25, 2015.
15
Ralston
JD
,
Coleman
K
,
Reid
RJ
,
Handley
MR
,
Larson
EB
.
Patient experience should be part of meaningful-use criteria
.
Health Affairs (Millwood)
.
2010
;
29
(
4
):
607
613
.
16
Mion
L
,
Chandler
A
,
Waters
T
, et al
.
Is it possible to identify risks for injurious falls in hospitalized patients?
Jt Comm J Qual Patient Saf
2012
;
38
(
9
):
408
413
.
17
Carpenter
CR
,
Scheatzle
MD
,
D’Antonio
JA
,
Ricci
PT
,
Coben
JH
.
Identification of fall risk factors in older adult emergency department patients
.
Acad Emerg Med
.
2009
;
16
(
3
):
211
219
.
18
Stern
C
,
Jayasekara
R
.
Interventions to reduce the incidence of falls in older adult patients in acute-care hospitals: a systematic review
.
Int J Evid Based Healthc
.
2009
;
7
(
4
):
243
249
.
19
Hempel
S
,
Newberry
S
,
Wang
Z
, et al
.
Hospital fall prevention: a systematic review of implementation, components, adherence, and effectiveness
.
J Am Geriatr Soc
.
2013
;
61
(
4
):
483
494
.
20
Rowe
J
.
Preventing patient falls: what are the factors in hospital settings that help reduce and prevent inpatient falls
.
Home Health Care Manag Pract
.
2013
;
25
(
3
):
98
103
.
21
Schmid
N
.
Reducing patient falls: a research-based comprehensive fall prevention program
.
Mil Med
.
1990
;
155
:
202
207
.
22
Yardley
L
,
Beyer
N
,
Hauer
K
,
McKee
K
,
Ballinger
C
,
Todd
C
.
Recommendations for promoting the engagement of older people in activities to prevent falls
.
Qual Saf Health Care
.
2007
;
16
(
3
):
230
234
.
23
van Gaal
B
,
Schoonhoven
L
,
Mintjes
J
, et al
.
Fewer adverse events as a result of the SAFE or SORRY? programme in hospitals and nursing homes, I: primary outcome of a cluster randomised trial
.
Int J Nurs Stud
.
2011
;
48
(
9
):
1040
1048
.
24
Ferrari
M
,
Harrison
B
,
Lewis
D
.
The risk factors for impulsivity-related falls among hospitalized older adults
.
Rehabil Nurs
.
2012
;
37
(
3
):
145
150
.
25
Morse
J
,
McFarlane-Klob
H
.
The Modified Morse Fall Scale
.
Int J Nurs Prac
.
2006
;
12
(
3
):
174
175
.
26
Yardley
L
,
Nyman
S
.
Internet provision of tailored advice on falls prevention activities for older people: a randomized controlled evaluation
.
Health Promot Int
.
2007
;
22
(
2
):
122
128
.
27
Tzeng
H
,
Chang-Yi
Y
.
Toileting-related inpatient falls in adult acute care settings
.
Medsurg Nurs
.
2012
;
21
(
6
):
372
377
.
28
Swartzell
K
,
Fulton
J
,
Friesh
B
.
Relationship between occurrence of falls and fall-risk scores in an acute care setting using the Hendrich II Fall Risk Model
.
Medsurg Nurs
.
2013
;
22
(
3
):
180
187
.
29
Cameron
I
,
Gillespie
L
,
Robertson
M
, et al
.
Interventions for preventing falls in older people in care facilities and hospitals
.
Cochrane Database Syst Rev
.
2012
;(
12
):
CD005465
.
30
Aromataris
E
.
Interventions to reduce the incidence of falls in older adult patients in acute care hospitals
.
J Adv Nurs
.
2010
;
66
(
6
):
1209
1211
.
31
Oliver
D
.
Prevention of falls in hospital inpatients: agenda for research and practice
.
Age Ageing
.
2004
;
33
(
4
):
328
330
.
32
Liu-Ambrose
TY
,
Khan
KM
,
Eng
JJ
,
Gillies
GL
,
Lord
SR
,
McKay
HA
.
The beneficial effects of group-based exercises on fall risk profile and physical activity persist 1 year post-intervention in older women with low bone mass: follow-up after withdrawal of exercise
.
J Am Geriatr Soc
.
2005
;
53
(
10
):
1767
1773
.
33
Yardley
L
,
Donovan-Hall
M
,
Francis
K
,
Todd
C
.
Attitudes and beliefs that predict older people’s intention to undertake strength and balance training
.
J Gerontol B Psychol Sci Soc Sci
.
2007
;
62
(
2
):
P119
P125
.
34
Fuzhong
L
,
McAuley
E
,
Fisher
KJ
,
Harmer
P
,
Chaumeton
N
,
Wilson
NL
.
Self-efficacy as a mediator between fear of falling and functional ability in the elderly
.
J Aging Health
.
2002
;
14
(
4
):
452
466
.
35
Kempen
G
,
Yardley
L
,
van Haastregt
J
, et al
.
The Short FES-I: a shortened version of the Falls Efficacy Scale-International to assess fear of falling
.
Age Ageing
.
2008
;
37
(
1
):
45
50
.
36
Yardley
L
,
Smith
H
.
A prospective study of the relationship between feared consequences of falling and avoidance of activity in community-living older people
.
Gerontologist
.
2002
;
42
:
17
23
.
37
Tinetti
M
,
Richman
D
,
Powell
L
.
Falls efficacy as a measure of fear of falling
.
J Gerontol
.
1990
;
45
(
6
):
P239
P243
.
38
National Priorities Partnership
.
National Quality Forum
. . Accessed May 26, 2015.
39
US Department of Health and Human Services
.
2012
Annual Progress Report to Congress: National Strategy for Quality Improvement in Health Care
.
http://www.ahrq.gov/workingforquality/nqs/nqs2012annlrpt.pdf. Published pril 2012. Corrected August 2012 and May 2014
. Accessed May 26, 2015.
40
Longtin
Y
,
Sax
H
,
Leape
LL
,
Sheridan
SE
,
Donaldson
L
,
Pittet
D
.
Patient participation: current knowledge and applicability to patient safety
.
Mayo Clin Proc
.
2010
;
85
(
1
):
53
62
.
41
Sahlsten
MJ
,
Larsson
IE
,
Sjöström
B
,
Plos
KA
.
Nurse strategies for optimising patient participation in nursing care
.
Scand J Caring Sci
.
2009
;
23
(
3
):
490
497
.
42
Davis
RE
,
Jacklin
R
,
Sevdalis
N
,
Vincent
CA
.
Patient involvement in patient safety: what factors influence patient participation and engagement?
Health Expect
2007
;
10
(
3
):
259
267
.
43
Rogers
R
.
A protection motivation theory of fear appeals and attitude change
.
J Psychol
.
1975
;
91
(
1
);
94
114
.
44
Milne
S
,
Sheeran
P
,
Orbell
S
.
Prediction and intervention in health-related behavior: a meta-analytic review of protection motivation theory
.
J Appl Soc Psychol
.
2000
;
30
(
1
):
106
143
.
45
Ruiter
R
,
Abraham
C
,
Kok
G
.
Scary warnings and rational precautions: a review of the psychology of fear appeals
.
Psychol Health
.
2001
;
16
:
613
630
.
46
Witte
K
,
Allen
M
.
A meta-analysis of fear appeals: implications for effective public health campaigns
.
Health Educ Behav
.
2000
;
27
(
5
):
591
615
.
47
Bandura
A
.
Health promotion by social cognitive means
.
Health Educ Behav
.
2004
;
31
;
143
164
.
48
Hsieh
F
,
Bloch
D
,
Larsen
M
.
A simple method of sample size calculation for linear and logistic regression
.
Stat Med
.
1998
;
17
(
14
):
1623
1634
.
49
Borson
S
,
Scanlan
J
,
Brush
M
,
Vitaliano
P
,
Dokmak
A
.
The Mini-Cog: a cognitive vital signs measure for dementia screening in multi-lingual elderly
.
Int J Geriatr Psychiatry
.
2000
;
15
(
11
):
1021
1027
.
50
Inouye
SK
,
van Dyck
CH
,
Alessi
CA
,
Balkin
S
,
Siegal
AP
,
Horwitz
RI
.
Clarifying confusion: the Confusion Assessment Method. A new method for detection of delirium
.
Ann Intern Med
.
1990
;
113
(
12
):
941
948
.
51
Hausdorff
J
,
Rios
D
,
Edelber
H
.
Gait variability and fall risk in community-living older adults: a 1-year prospective study
.
Arch Phys Med Rehabil
.
2001
;
82
(
8
):
1050
1056
.
52
Sonnad
SS
,
Mascioli
S
,
Cunningham
J
,
Goldsack
J
.
Do patients accurately perceive their fall risk?
Nursing
2014
:
44
(
11
):
58
62
.
53
Oliver
D
,
Healey
F
,
Haines
T
.
Preventing falls and fall-related injuries in hospitals
.
Clin Geriatr Med
.
2010
;
26
:
645
692
.
54
Haas
R
,
Haines
T
.
Twelve month follow up of a falls prevention program in older adults from diverse populations in Australia: a qualitative study
.
Arch Gerontol Geriatr
.
2014
;
58
(
2
):
283
292
.
55
Tzeng
H
.
Nurses’ caring attitude: fall prevention program implementation as an example of its importance
.
Nurs Forum
.
2011
;
46
(
3
):
137
145
.
56
Quigley
P
,
Hahm
B
,
Gibson
W
, et al
.
Reducing serious injury from falls in two veterans’ hospital medical-surgical units
.
J Nurs Care Qual
.
2009
;
24
(
1
):
33
41
.
57
Minnesota Hospital Association
.
Preventing patient falls
. . Accessed June 23, 2015.

Footnotes

FINANCIAL DISCLOSURES

This study was supported by an AACN-Philips Healthcare Clinical Outcomes Grant.

eLetters

Now that you’ve read the article, create or contribute to an online discussion on this topic. Visit www.ajcconline.org and click “Submit a response” in either the full-text or PDF view of the article.

SEE ALSO

For more about fall prevention, visit the Critical Care Nurse Web site, www.ccnonline.org, and read the article by Cangany et al, “Bedside Nurses Leading the Way for Falls Prevention: An Evidence-Based Approach” (April 2015).

To purchase electronic or print reprints, contact American Association of Critical-Care Nurses, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 899-1712 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints@aacn.org.