CHAPTER I

THE PROBLEM AND ITS BACKGROUND

Introduction

Fall resulting to injury is still a prevalent patient safety problem occurring in any health

care facilities until today. It is consistently among the Top 10 sentinel events reported majority

of which occurs in hospital settings. Statistics would show that about 63% of these fall resulted

to death while the rest sustained serious injuries (Joint Commission International, 2015). In the

Philippines, death resulting from falls ranked 32nd among the Top 50 causes of death and

accounts for 3, 246 deaths per year (World Health Rankings, 2014).

Protocols had already been established as a measure in prevention of fall. The Joint

Commission’s International Patient Safety Goal 6 (IPSG 6) is to reduce the risk of patient harm

resulting from falls. Those who fall are two or three times more likely to fall again. Over the

past three decades, research has developed to the point where we are able to predict which

patients are likely to fall based on the frailty associated with illness and aging and to implement

strategies to prevent the fall or to protect the patient from injury, should a serious fall occur

(Morse, 2009).In the context of the population it serves, the services it provides, and its

environment of care, a health care organization should evaluate the patient’s risk for falls and

take action to reduce the risk of falling as well as the risk of injury, should a fall occur (The

Joint Commission, 2009a).

Elderly and frail patients are not the only ones who ae susceptible or vulnerable to fall

injury but likely include patient of any age which can be attributed to physiological changes

1
brought about by either their medical condition, medications taken, surgery, procedures or

diagnostic testing that can leave them weakened or confused. Falls are considered one of the

nursing sensitive quality indicators (ANA, 2009). Rush (2009) emphasized that no health

care professionals are affected more by falls than nurses who work in the hospital on the

frontlines of patient care. Moreover, patient falls are serious problems in acute care hospitals

and are used as a standard metric of nursing care quality (Dykes et al., 2009)

In a tertiary hospital in Quezon City where the researcher is working as a staff nurse,

fall incidents are being targeted to be zero however, it still continues to be one of the main

concerns. On the average of 29,868 hospital admissions per year, with 2489 admissions per

month, and roughly 83 admissions per day, patients who are at high risk for fall category

(including newly admitted and patients who are already admitted regardless of admission days)

are on the average of 133 per day (Endorsement Tagging Report for High Risk for Fall report

as of April 2, 2016). The most recent fall data provided by the facilityfor the first 2 quartersof

2016 is 2, indicating 2 reported cases of fall within the first 4 months of the year, although the

number of level III and level IV trauma is zero per 1000 patient days, meeting the Joint

Commission’s standard. Those fall incidents occurred in the ward where the researcher is

currently assigned at. Last 2015, fall rate is at .08 which is still far from the targeted 0 fall rate

in a year.

Thehospital has an establishedFall Prevention and Management policy (please see

Appendix D for detailed discussion of the policy). The policy shall apply to all groups and

departments admitting, providing services and giving care to patients.The key aspects of this

policy are to establish a multidisciplinary team, implement a fall risk assessment requirement

for all patients, educate the patients, patient’s family, and associates about the hospital’s fall

2
prevention and management program, including interventions to prevent falls ensuring that fall

incidents are monitored and reported and causes and pre-dispositions are analyzed.

Despite the measures being implemented to reduce and eradicate the incidence of fall

in the selected hospital, patient falls still occur. The most recent fall data already accounts for

2 fall incidents in the hospital for the first 4 months of the year, of which the general unit

involved is the ward where the researcher is assigned. If the measures are already available but

fall incidents still continue to be present, then there must be something lacking or there exists

a gap in implementation. In this context, the compliance of the nurses with the implementation

of fall prevention protocol tends to be questionable. This motivated the researcher to assess the

nurses’ level of compliance with the fall prevention protocol, and describe their experiences

associated in implementing the measures.

Statement of the Problem

The study aims and to determine nurses’ compliance and describetheir experiences with

the Fall Prevention Protocol (FPP) in a selected tertiary hospital in Quezon City.

Specifically, it seeks to answer the following questions:

1. What is the profile variables of nurses in terms of:

a. Age;

b. Education: and

c. Length of experience?

3
 2. What is the level of compliance of nurses with the FPP in the following cluster unit

assignments?

a. Medical Surgical

b. Intensive

c. Maternal

3. Is there a significant difference in the level of compliance of nurses with the FPP in

terms of their cluster unit assignments when they are grouped according to their

profile variables?

4. What are the nurses’ experiences with the Fall Prevention Protocol?

Significance of the Study

This study is essential because it may determine the nurses’ compliance with

the standard fall prevention protocol and their experiences

Nursing Practice

For nursing practice, the study is highly relevant to nursing due to the fact that

it is aimed at prevention of falls in inpatients by strengthening the compliance with the

fall prevention protocol and that the major responsibility of preventing inpatient falls

rests on the shoulder of the nursing workforce. The study can be an encouragement for

the improvement of quality of service rendered to patients.

4
Nursing Education

For nursing education, it can provide evidence-based information for the

possible clinical advancement of nurses. This study may deliver actual information

about the nurses’ compliance in implementing the presently available fall prevention

protocol their experiences associated with implementing the measures. An in-house

training can also be developed strengthening and refreshing the compliance in correctly

identify patients that are at high risk for fall using the Morse Fall Scale, fall risk

reassessment form, and to develop a nursing care plan aimed at reducing the incidents

of fall. This study may also serve as a basis for the hospital’s fall committee for

revisions and/or improvement of presently available forms and protocol.

Nursing Administration

For nursing administration,this research may provide an evidence-based

reference to the nursing managementthat patient fall rates are the indicators that could

be most improved through compliance with established protocols. That this study may

serve as a basis to review the existing policy and revise or formulate a new, that can be

implemented to strengthen the compliance of nurses in implementing the fall

prevention protocol, thus reducing the incident rates of fall.

5
 Nursing Research

For nursing research, that this study may motivate other researchers locally and

internationally, to conduct further studies to determine the compliance of nurses in

using the fall prevention protocol and their experiences associated with implementing

the measures. That this research may strengthen the existing literatures providing data

on one of the nursing sensitive quality indicators, fall. Likewise, this study can also

influence nursing research bodies in publishing more journals and studies, therefore,

extending the body of evidence-based literature.

Scope and Limitation

This research will focus on determining the nurses’ level compliance with the standard

Fall Prevention Protocol and describing their experiences in a selected hospital in Quezon City.

The study will use the Mixed Methods Approach of Quantitative and Qualitative

research, specifically an explanatory sequential design. The study will be conducted within a

3-month period from June 6to August 26, 2016.The research locale chosen will be the tertiary

hospital where the researcher is affiliated, and the population will bestaffnurses from all the

nursing units of the selected hospital. Inclusion criteria will be: staff nurses with at least 1 year

to a maximum of 10 years of current bedside experience in the research locale, working full

time; to facilitate maximum recall of experience and in order for them to have felt different

experiences in implementing the FPP.

The nurse unit manager and nursingaides will not be included in the study. Moreover,

participants who have less than 1 year experience in the general unit, have stopped bedside

6
experience for more than 1 year and who have current administrative positions will be excluded

from the study.

Definition of Terms

The variables of the study are defined in this study:

Level of Compliance

This refers to the way the…(Reyes, 2013)

In the study, this refers to the…

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 Chapter 2

REVIEW OF RELATED LITERATURE

This chapter presents a review of researches, published articles, and other literature

which are highly relevant and useful to the conduct of this study. A synthesis of the reviewed

literature is also presented in this portion.

Fall in healthcare facilities

Falls can occur in a home, community, long-term rehabilitation, or acute care setting.

The rate of falls in acute-care hospitals is estimated to range from 1.3 to 8.9 per 1,000 bed-

days,which translates into well over 1000 falls per year in a large facility (Isomi, M.,2013).

Higher rates are reported in particular sites or wards, such as those specializing in neurology,

geriatrics, and rehabilitation. Because falls are believed to be underreported, most estimates

are assumed to be overly conservative (Oliver, D., 2010). However defining what is a “fall” is

itself a challenge, as there is variability in the research literature and among older adults about

what constitutes a fall (Zecevic, A., 2006). Authoritative bodies have definitions (e.g., the

NQF (National Quality Forum) defines a fall as “an unplanned descent to the floor without

injury” and WHO (World Health Organization) defines a fall as “an event which results in a

person coming to rest inadvertently on the ground or floor or some lower level” , but even after

accepting a conceptual definition of a fall, there is a difference between any fall, a fall with

injury, the proportion of a population who has a fall, and the number of falls. Nevertheless,

there is widespread agreement that falls, however defined, occur frequently and can have

serious physical and psychological consequences. Between 30 percent and 50 percent of in-

8
facility falls are associated with reports of injuries. Hip fractures occur in 1 percent to 2 percent

of falls (Isomi, M.,2013). Inpatient falls are also associated with increased health care

utilization, including increased length of stay and higher rates of discharge from hospitals into

institutional or long-term care facilities. In one recent analysis in three hospitals in Missouri,

operational costs for patients who have fallen with serious injuries were $13,000 higher than

for control patients without falls, and patients who have fallen had an additional 6.3 days' length

of stay (Wong, CA., 2013). Fall risk tends to be related mostly to mobility status, exposure to

hazardous environments and risk-taking behaviors such as climbing ladders for seniors living

in the community setting (Scott, Votova, Scanlan, & Close, 2007). An unfamiliar environment,

acute illness, surgery, bed rest, medications, treatments, and the placement of various tubes and

catheters are common factors that place patients at risk for falling in the hospital setting (Dykes,

Carroll, Hurley, Benoit, & Middleton, 2009). Even falls that do not cause severe injuries can

trigger a fear of falling, anxiety, distress, depression, and reduced physical activity. Family

members, caregivers, and health care professionals are also susceptible to overly protective or

emotional reactions to falls, which can also impact the patient's independence and

rehabilitation.While the risk factors for a fall in hospitalized adults are greatly influenced by

acute illness that often has a marked, albeit temporary, impact on physical and cognitive

function compounded by care provided in unfamiliar surroundings (Scott et al., 2007), in the

long-term care setting, the risk factors for falls are influenced by impaired cognition, wandering

or impulsive behavior, use of psychotropic medications, incontinence and urgency, lack of

exercise, unsafe environments, and low staffing levels. Patient falls are serious problems in

acute care hospitals and are used as a standard metric of nursing care quality (Dykes etal.,

2009). Although, there is a sense of urgency in hospitals to prevent falls to “do no harm” and

also because Medicare will not reimburse hospitalization costs due to fall related injuries,

patient falls remain a serious problem in U.S. hospitals (Dykes et al., 2009). According to

9
Morse 1993, patient falls in an institution are not random events. Patient falls are patterned and

predictable and, therefore, a preventable occurrence. Around this premise, entrenched in a

tradition of empirical knowing, a whole culture of fall prevention has developed, directing

nurses in fall risk assessments and targeted interventions based on best evidence as discussed

above (Rush et al., 2009). As with other outcome measures (e.g., pressure ulcers, urinary tract

infections, pneumonia), nurses are in a position to influence patient outcomes. A local study

conducted by Guevarra in 2010 entitled “Falls among Filipino Elderly Persons”, stated that the

incidence and prevalence of falls in the elderly unfortunately continues to be high due to lack

of awareness of the risk factors. The key to effective prevention of falls in the elderly is the

identification of risk factors for falls and the implementation of interventions aimed at

modifying or eliminating the risk factors present.

International Patient Safety Goal 6

The Joint Commission under its IPSG 6 delineates that, to reduce the risk of patient

harm resulting from falls, hospitals should implement a fall reduction program that includes an

evaluation of the effectiveness of the program (The Joint Commission, 2009b). The fall

reduction programs should include an evaluation appropriate to thepatient population, settings,

and services provided. It should include interventions to reduce the patient’s fall risk factors

(The Joint Commission, 2009a). Furthermore, TJC (2013) requires accredited hospitals to

conduct fall risk assessments for hospitalized patients to identify patients’ risk for falls so that

prevention measures can be implemented into the plan of care (The Joint Commission, 2013).

Staff should receive education and training about fall reduction programs. The hospital should

educate the patient and, as needed, the family on the fall reduction program and any

individualized fall reduction strategies. The hospital should evaluate the fall reduction program

10
to determine the effectiveness of the program (The Joint Commission, 2009a). Within these

guidelines, it is up to the hospital to develop an individually tailored program for the

organization. For example, there are multiple fall risk assessment tools available in the

literature, such as the Morse Fall Scale (Morse et al., 1989), St. Francis Hospital Safety

Assessment Tool (Dacenko-Grawe & Holm, 2008), and others. Each hospital chooses its own

assessment tool and develops its own practice guidelines from the evidence-based literature

available. Some fall prevention studies in acute care hospitals focus on the effectiveness of

specific interventions, such as hourly rounds by staff, use of a toileting schedule, and increased

RN staffing ratio, on reducing falls. For example, one study found that lower fall rates were

associated with higher staffing up to a specific point – 15 nursing hours per patient day – on

step-down, medical, and combined medical-surgical units (Dunton, Gajewski, Taunton, &

Moore, 2004). Nursing hours per patient day is the total number of hours worked by nursing

staff who are involved at least 50% of the time in direct patient care/total number of patient

days (Dunton, Gajewski, Taunton, & Moore, 2004).

The Joint Commission began to monitor sentinel events in 1995, and through the end

of 2012, there have been 659 fall related events which resulted in death or permanent loss of

function that were voluntarily reported as a sentinel event. This number reflects voluntary

reporting and represents only a small portion of actual events. The actual number is unknown

but is most likely much greater, attesting to the importance of fall prevention interventions.

What is clear is that patients are still falling in hospitals and experiencing injury (The Joint

Commission, n.d.). The depth and breadth of program evaluation must be expanded; applying

the concepts from high reliability organizations can assist in better results. Dr. Mark Chassin,

current President of TJC, and Dr. Jerod Loeb, executive vice president, conclude that the health

care industry can achieve excellence in safety and quality through three components that

11
support high reliability – leadership, safety culture, and robust process improvement (Chassin

& Loeb, 2011). Through these processes, care can be made more effective, efficient, and less

vulnerable to failure which may result in patient harm

Interdisciplinary Approach

Safe culture is further strengthened by strong interdisciplinary teams, which includes

collaboration and cooperation among leaders, nursing staff, and staff from other

disciplines. Teams should apply evidence-based practices to improve standardization and

reduce unwanted variation in processes. Effective teams are manifested by open

communication whereby leaders facilitate each member' ability to speak up on behalf of a

patient, and in which teams have a clear vision and purpose of the roles of each member. Teams

need regular feedback and should be capable of correcting behaviors that do not promote

patient safety. Members in a strong safety culture demonstrate clear communication among all

staff and this communication is frequent. Frequent, open communication engenders trust

among members, and there is ongoing learning in which healthcare system leaders gain wisdom

from mistakes and seek to continually improve processes and performance. Safe culture is one

that views errors as system failures rather than individual failures (Beaudin & Pelletier,

2012; Byers & White, 2004; IOM, 1999; Riley, 2008). The entire focus is patient-centered;

safety and quality of care in the health care system is centered on patients and families.

Some studies focused on interdisciplinary approaches where nurses worked

incollaboration with other disciplines, such as physical therapy, occupational therapy, and

pharmacy, to reduce falls. For example, one study evaluated an interdisciplinary (nursing and

physical therapy), multi-interventional fall prevention protocol (Gutierrez & Smith, 2008),

12
while other studies use a comprehensive approach of preventing falls tailored toaddress the

various intrinsic and extrinsic factors that contribute to falls in elderly patients (Labonte, Klock,

& Houser, 2008; Murphy et al., 2008). This particular study examined the implementation of

a successful multifaceted program wherein a staff-led unit practice council developed an

evidence-based intervention plan. Staff-led unit practice councils consist of staff members of

the unit discuss nursing practice issues and make plans for remediation (Murphy et al., 2008).

The interventions included a campaign to raise geriatric awareness, creation of “fall tool

boxes,” education of staff and family, and implementation of a structured hourly patient rounds

schedule (Murphy et al., 2008).

Compliance and Barriers

Nurses play a key role in ensuring quality and patient safety in health care. Nurses are

most likely to spend the greatest amount of time with patients and are in a strong position to

monitor and mitigate risks and improve patient outcomes. While nurses may impact numerous

clinical processes and outcomes, the example of falls and injury prevention as nurse sensitive

measures is reviewed as an exemplar framework for demonstrating safe, quality care at the

organization, unit, and patient level. Three articles were found to be of high relevance to the

author’s study. The search was narrowed to articles directly related to the implementation of

FPPs in acute caresettings. Dacenko-Grawe and Holm (2008) describe a quantitative study on

successful implementation of an evidence-based FPP called the Saint Francis Hospital (SFH)

FPP. There was approximately a 50% reduction in the number of falls per 1000 patient days

over a five year period. All nine units of this 325-bed hospital were studied with comprehensive

fall data collected for the whole hospital. The greatest decline in the fall rate was seen in the

first year of the protocol’s implementation. Broad communication to all hospital staff beyond

13
bedside caregivers contributed to a continuing decline in the absolute number of falls.

Vigilance in observing patients at risk for falls was enhanced by sharing accountability with

all staff members on a nursing unit and not just those involved in direct patient care. This study

is limited by the fact that it does not measure nursing compliance or identify barriers

experienced by nurses and other staff members in implementing the FPPs.

Tzeng and Yin (2008) describe a qualitative study of nurses’ perspectives in

comparison to the five dimensions of individual fall risk factors as identified by The Joint

Commission: inadequate caregiver communication, inadequate staff orientation and training,

inadequate assessment and reassessment, unsafe care environment, and inadequate care

planning and provision. Tzeng and Yin’s study investigated the nurses’ perceived barriers in

implementing fall prevention. Out of 40 nurses who worked in a particular acute medical unit,

nine nurses volunteered to participate in the study. Data were collected through individual

interviews, which were audiotaped. In this study, researchers used inductive and deductive

methods to understand the clinically accessible solutions to minimize the extrinsic factors of

inpatient falls. The findings from the nurse interviews were compared with the intervention

strategies toward the five primary root causes of falls as suggested by The Joint Commission.

Twenty-four solutions were identified from the nurse interview transcriptions; five were related

to the dimension of inadequate caregiver communication, none was associated with the

dimension of inadequate staff orientation and training, three were related to inadequate

assessment and reassessment, 15 were associated with unsafe care environment, and one was

related to inadequate care planning and provision. This study is of limited relevance in that it

did not measure nursing compliance with FPPs.

14
 Gutierrez and Smith (2008) describe a quantitative study that was closely related to the

current study, as it was aimed at measuring nursing compliance and identifying barriers. A

Specialty Adult Focused Environment (SAFE) unit was created for high fall risk patients,

staffed with two RNs and one technical partner (equivalent of a certified nursing assistant

(CNA) for six patients. Using an evidence-based framework for evaluating evidence,

experience, and values, qualitative and quantitative data points were selected on the basis of a

literature review targeted to identify universal barriers toimplementing an interdisciplinary,

multifactorial FPP. The audit process routinely evaluated what the system process was, whether

the nurse had followed the policy, and whether barriers had prevented the implementation of

the policy. A Rounding Tool was developed and used to see whether an FPP was initiated and

implemented for patients identified at high-risk for falls by the nurses. The literature suggests

that a fall risk assessment followed by FPP initiation in the identified high risk population is

effective in the prevention of falls.

Although a few studies briefly mentioned patient safety culture, teamwork, or leadership,

only four studies presented expanded explanations that merited mention. Grenier-

Sennelier(2002) use a framework from Shortell and colleagues(1995) to analyze safety on the

unit level, teamwork at both the organizational and unit level, and leadership on the

organizational and unit level. Stenvall discusses teamwork at the unit level of their article. Koh

discusses leadership on the organizational and unit level: “Successful implementation is

mediated by strong leadership and environmental support, which are integral to building

positive attitudes among nurses, ensuring that the sociocultural environment is conducive to

the process of change. In the study of Isomi (2013), the multifaceted strategy targeting barriers

to change exemplified the commitment of the leadership and environmental support. Van der

15
Helm (2003) made multiple observations addressing leadership on both the organizational and

unit level:

• “Although the clinical ward management underlined the importance of implementing

the guideline at the outset of the project, the actual support given was too weak to be

effective. Some managers expressed doubt about the project's chances for success to

the project leader, stating that implementation “had already failed before.” Ward staff

often regarded improvement activities as unwanted additional work that hindered daily

operations. The two senior nurses often displayed a delegating rather than a directive

management style, for example, in terms of ensuring that the risk assessment tool was

completed or all incidents reported.”

• “Nurses told us that the medical center did not take the falls problem seriously, which

therefore undermined their own motivation to contribute to the project's success.”

• A measure in the Questionnaire Regarding Knowledge of the Guideline and Attitude

Toward Implementation, “There is enough support from the management for guideline

implementation” scored 44% to 53%.

Synthesis

An analysis of the literature shows that most studies recommend a comprehensive

interdisciplinary approach for the prevention of falls, but the nursing workforce is at the center

of this approach. Falls violate nurses’ legal and ethical responsibility to do no harm and are

contrary to the culture of institutional safety promoted at every level of health care (Rush et

al., 2009). Falls may undermine the quality of the relationship between nurse and patient when

nurses who are expected to know a patient’s fall risk allow patients to fall (Rush et al., 2009).

Through assessment and surveillance activities, nurses have the capacity to analyze, anticipate,

and identify fall risks and to institute plan for fall prevention (Murphy et al., 2008). Nurses’

16
compliance is mainly affected by management support in the implementation of the guidelines

(Van der Helm, 2003).

Theoretical Framework

This study will anchor in the Self-Determination theory (Deci, E. & Ryan, R., 1985).

This theory represents a broad framework for the study of human motivation and personality.

SDT articulates a meta-theory for framing motivational studies, a formal theory that defines

intrinsic and varied extrinsic sources of motivation and a description of the respective roles of

intrinsic and types of extrinsic motivation in cognitive and social development and in

individual differences. Conditions supporting the individual’s experience of autonomy,

competence and relatedness are argued to foster the most volitional and high quality forms of

motivation and engagement for activities, including enhanced performance, persistence and

creativity. In addition, SDT proposes that the degree to which any of these three psychological

needs is unsupported or thwarted within a social context will have a robust detrimental impact

on wellness in that setting. People are centrally concerned with motivation- how to move

themselves or others to act. They are often moved by external factors such as reward systems,

grades, evaluations, or the opinions they fear others might have of them. The interplay between

the extrinsic forces acting on persons and the intrinsic motives and needs inherent in human

nature is the territory of Self Determination theory.

Nurses’ level of compliance with fall prevention protocol is affected by the intrinsic

and extrinsic factors. These intrinsic and extrinsic factors are the cluster unit assignments and

the profile variables – age, education and length of experiences of the nurses who will be the

respondents of the study in the quantitative phase.

17
 Additionally, the nurse participants’ experiences with the FPP will be another factor

that will describe in the qualitative phase of the study.

ResearchParadigm

NURSES’ PROFILE
VARIABLES

a. AGE
b. EDUCATION
c. LENGTH OF
EXPERIENCE

NURSES’ LEVEL OF
COMPLIANCE IN FALL
PREVENTION
PROTOCOL IN TERMS FALL HIGH RISK
OF CLUSTER UNIT PREVENTION
ASSIGNMENTS:
PATIENTS FOR
a. MEDICAL- PROTOCOL FALL
SURGICAL INCIDENTS
b. INTENSIVE
c. MATERNAL
AND CHILD

Figure 1. Nurses’ Compliance with the Fall Prevention Protocol

Figure 1 shows the paradigm of Nurses’ Compliance with Fall Prevention Protocol and

the variables that will be studied in this research.The paradigm is represented by two (2) boxes,

two overlapping circles and one (1) double headed arrow and two (2) single headed arrow. The

18
1st BOX represents nurses’ profile variables in terms of age, education, and length of

experience, while the 2nd BOX corresponds to the level of compliance of nurses with the FPP

in terms of cluster unit assignments.

Furthermore, the overlapping circles represent (1) theFPP of hospital research locale and(2)

the patients who will be classified as high risks for fall that are assessed from utilizing the FPP.

Thebasis for determining the level of compliance of nurses in terms of their cluster unit

assignments will be based from patients’ record and environmental audit guided by the

Rounding Tool.

The black arrow pointing to the overlapping circles from the 1st BOXof nurses’ profile

variables indicates that nurses’ compliance with the FPP are influenced by their profile

variables.

Another black arrow pointing to the overlapping circles from 2nd BOX represents the

nurses’ level of compliance with the FPP in terms of cluster unit assignment which means that

nurses’ level of compliance can be affected by their cluster unit assignments.

The double headed arrow signifies difference connecting 1st BOX and the 2nd BOX

which indicates the difference in nurses’ level of compliance with the FPP in terms of cluster

unit assignments when they are grouped according to their profile variables.

Nevertheless, the paradigm shows the connection between the variables of the study.

Nurses’ profile variables and nurses’ cluster unit assignments can be interrelatedly connected

to each other which affects their compliance with the hospital’s FPP, for the patients identified

to be at high risk for fall.

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 Chapter III

RESEARCH METHODOLOGY

This chapter presents the design of the study, the description of the research setting

and subject of the study, research instruments and the statistical procedures to be used in

treating the data to be gathered.

Research Design

The research design that will be used in conducting the study is a mixed method of

quantitative and qualitative design. Mixed methods research is the type of research in which a

researcher combines elements of qualitative and quantitative research approaches for the broad

purposes of breadth, and depth of understanding and corroboration (Nunez- Smith, 2015).

Specifically, an explanatory sequential design will be utilized.In this approach, the

quantitative components will be conducted first followed by the qualitative components

(Nunez-Smith, 2015). The qualitative component may therefore generate stand-alone findings

as well as inform the quantitative component, or it may simply serve as a secondary function

to support the primary quantitative aim.The data will be integrated through connecting two

data sets. Connecting will occur when one type of data builds upon the other (Creswell & Plano

Clark, 2011). Synthesis of information also called as triangulation, will occur throughout the

process of data collection in order to generate a rich, multidimensional description of the case

(Nunez-Smith, 2015).

20
 Since the study will be directed at determining the nurses’ compliance with an FPP, the

design will bequantitative, specifically, descriptive. Under the definition of Burns and Grove

(2013), a quantitative research is a formal, objective, rigorous, systematic process for

generating numerical information around the world. It is conducted to describe new situations,

events, or concepts; examine relationships among variables, and determine the effectiveness of

treatments. For the purpose of this study, the descriptive type of quantitative research will be

utilized as it is the exploration and description of phenomena in real-life situations. It provides

an accurate account of characteristics of particular individuals, situations, or groups (Kerlinger

& Lee, 2000). No interventions will be used to improve staff compliance with the FPP and no

changes will be made to the existing standardized protocol. The level of compliance will be

identified through the review of patients’ chart and environmental audit using the Rounding

Tool.

For the qualitative phase to determine nurses’ experiences with FPP, the design that

will be used is simple qualitative. Qualitative research is a systematic, subjective approach used

to describe life experiences and give them meaning (Burns & Grove, 2013). The reasoning

process involves perceptually putting pieces together to make wholes. From this process,

meaning is produced. Because perception varies with the individual, many different meanings

are possible (Munhall, 2007). To determine the nurses’ experiences with the FPP, naturalistic

inquiry will be used.It involves studying real-world situations as they unfold naturally,

nonmanipulative and noncontrolling.

21
 This study will work from the pragmatist paradigm.Pragmatists view reality from two

perspectives. One reality is consistent with the positivists’ and post positivists’ views of reality.

That is, there is a reality outside the human that can be observed, measured, and understood in

some extent. Pragmatists’ second perspective of reality is that there is no one truth, but several

explanations of reality(Teddlie & Tashkkori, 2009).In understanding human behavior or

experience, which is a central concern of nursing, it requires that the person interpret the action

or experience for the researcher; the researcher must then interpret the explanation provided by

the person.

Research Locale

The study will be conducted in all of the nursing units of the selected tertiary hospital

in Quezon City. The tertiary hospital in Quezon City was chosen because the researcher finds

a gap between the implementation of protocol and the nurses’ compliance in this locale. All

the nursing units in this hospital will be considered so as to extract the most accurate data

possible in this research.

The said tertiary hospital has a total of 650 bed capacity, of which the total admission

is on the average of 29,868 hospital admissions per year, with 2489 admissions per month, and

roughly 83 admissions per day; patients who are at high risk for fall category (including newly

admitted and patients who are already admitted regardless of admission days) are on the

average of 133 per day (Endorsement Tagging Report for High Risk for Fall report as of April

2, 2016). The researcher will obtain permission to the selected tertiary hospital to do chart audit

and environmental review as well as interviews with the subjects.

22
Research Instrument

As the primary tool in the acquisition of relevant data, consisting of questions that are

geared towards eliciting the most precise and concrete answers from the respondents will be

utilized. For this reason, the researcher adapted a duly validated questionnaire from Anuradha

Thirumalai (2010). It is from an open source at UNLV University Libraries- University of Las

Vegas, and for the purpose of this study, the researcher formally asked the author through

electronic mail for permission to use his research tools.

The level of compliance among nursing staff will be measured using the ScrippsMercy

Hospital Rounding Tool (Rounding Tool) for patients identified at high risk forfalls

(Thirumalai, 2010). The degree of compliance with the FPP will be gradedaccording to the

scores obtained on the tool as high, moderate, or low compliance.

The Rounding Tool will be modified to fit in the current study (Please see Appendix

C).The wording in the original tool was changed to match the term used by the selected Tertiary

Hospital. Forexample, a “falling star” sign was used in the original tool, which was changed to

a“Kilroy” sign as used by the research locale in the modified tool. Two items will be omitted

fromthe original tool since there was no objective way to gather information on these items.The

omitted items are whether fall risk was given in verbal report and if transportpersonnel were

educated by RN regarding patient fall-risk level and fall-riskinterventions. Additional items

included are accomplishing of hourly rounds for fall form, giving of fall brochure and the sign

in room/do not fall will be replaced by the instruction of call nurse for assistance written in the

communication board. Items that are not applicable to the research locale’sFPP will be

23
removed from thequestionnaire such as preformatted physician orders for high fall risk

patients, which the hospital does not use.

Validity and reliability testing will be done on the modified tools. Content validity

index(CVI) can be calculated by having experts rate items on a four-point scale (from 1 =

notrelevant to 4 = very relevant). The CVI for the total instrument is the proportion of

itemsrated as either 3 or 4. A CVI score of .80 or better indicates good content validity (Polit

&Beck, 2004). Content validity for the Rounding Tool will be established viaa panel of experts

(Fall Committee of the research locale) at the study site.

Sampling Method

The Independent Sampling will be used in this study. In mixed method research,

independent sampling is a primary purposeful sampling technique chosen for the qualitative

component, and a primary probability sampling technique is chosen for the quantitative

component (Nunez-Smith, 2015). The selection of the specific techniques is determined

separately based upon the research question developed for each component. The sampling plan

include two distinct samples although the component samples may still be linked or connected

even if the sampling frames are built independently.

For the quantitative part, thequota sampling will be used. This type of sampling uses a

convenience sampling techniques with an added feature- a strategy to ensure the inclusion of

subject types likely to be underrepresented in the convenience sample. The goal it to replicate

24
the proportions of subgroup present in the target population that are important for achieving

representatives for the problem being studied.

For the qualitative part, a purposeful – convenience sampling will be used. It involves

selecting the initial participants using purposeful samplingand then conveniently selecting

from those samples who are presently available during that shift (Nunez- Smith, 2015).

Purposeful sampling plans enable researchers to select the information-rich cases to gain

insights and discover new meaning in their area of study (Munhall, 2007). To facilitate in-depth

interview, the study population will be staff nurses presently available during their shift of the

data gatheringday, qualified in the inclusion criteria, selected through purposive-convenience

sampling. Data collection will be stopped after the researcher had reached saturation point.

Data Gathering Procedure

The researcher will obtain a written permission from the management of the selected

tertiary hospital in Quezon City. The study will be conducted once the approval has been given.

First, high fall-risk patients will be identified through Endorsement Tagging of High

Fall Risk Patients to be accessed in the Health Care Reports online system by the hospital. An

environmental audit and paper chart review will be conductedto determine compliance of

nurses with the existing FPP, with the guidance of the Rounding Tool.Charts will be reviewed

in a single day (depending on the current census) and will identify high fall-risk patients. By

chart review, the researcher will check if the forms are properly accomplished such as the

Morse Fall Scale during admission day, Fall Risk Reassessment form if applicable, Hourly

Rounds for Fall, and Nursing Care Plans. For the environmental audit, the researcher will

25
examine the patients’ rooms for fall signage, and will determine whether the room is free from

clutter, and whether the call bells and other needed items are placed within reach and other

standard fall prevention measures. All of which falls on the standard Fall Prevention Protocol.

In the data gathering process of the qualitative aspect, the researcher will explain the

purpose of the study to the possible respondents, once the respondent agreed to participate in

the study he/she will be asked to sign a consent and they will be informed that their identity

will be protected and will give assurance that withdrawal from the study is permitted at any

point. Next, the researcher will interview each of the staff nurses using an interview set of

questions guided. The interview will take about 30 minutes to 1 hour completion.

In order to avoid any influence to staff nurses from the presence of managers,no nurse

unit managers will be included in the interview. The researcher will also explain that their

answers will not affect their workloads in any form.

APPROVAL TO CONDUCT THE STUDY

Selected tertiary hospital in Quezon City

SAMPLE SELECTION
Inclusion and Exclusion Criteria

IDENTIFICATION OF HIGH FALL-RISK PATIENTS

By accessing the Endorsement Tagging
for High Fall Risk Patients
In the Health Care Reports online system

26
 The CHART REVIEW and ENVIRONMENTAL
AUDIT guided by the Rounding Tool to determine the
compliance with FPP will be conducted based on the
target number of patients set in quota sampling per
cluster unit assignments of nurses.

REASSESSMENT of patients’ fall risk score will be

checked if Fall Risk Reassessment on the 7th day of
admission is accomplished (as per protocol for
reassessment), if the patient is discharged, access to
Medical Records section will be requested

QUANTITATIVE DATA WILL BE SUBJECTED

TO STATISTICAL TREATMENT to determine
nurses’ profile variable and level of compliance with
the FPP in terms of cluster unit assignments

Qualitative Data Collection

PURPOSE OF THE STUDY WILL BE EXPLAINED

AND INFORMED CONSENT will be obtained for
nurses who will agree to participate in the study.
Schedule and place of interview will be set.

INTERVIEW will be conducted to the participants for

30minutes -1 hour, or depending on the data that will
be obtained from interview per participant.

TRANSCRIPTION of the interviews will be done.

Ethical Consideration

27
 Protecting the health and safety of research subjects is imperative. In order to assure

subject safety, the researcher will have her study reviewed by the Ethics Review Board

(ERB).

Principle of Respect for Persons

Principle of Beneficence

Principle of Justice

Statistical Treatment of Data

After acquiring all the necessary data, the researcherwill collate and subject these to

statistical treatments. The collected data will be analyzed using Microsoft Excel program and

Statistical Package for the Social Sciences (SPSS). These data will be tabulated and analyzed

statistically using various statistical tools.

Response rate will be determined after successful collection of data. Response rate is

the rate of participation in a study, calculated by dividing the number of persons participating

by the number of persons sampled (Polit & Beck, 2004).

For the quantitative aspect of the study, frequency distributions and percentage will

be used to answer research question number 1, 2 and 3.

Ungrouped Frequency Distributions

28
 Frequency distributions will be the first method to be used to organize the data

for examination. Ungrouped frequency distributions will be developed to display all

numerical values obtained for a particular variable.

Percentage Distribution

Percentage distribution will indicate the percentage of participants in a sample

whose scores fall into a specific group and the number of scores in that group. It will

also be the basis for identifying the level of compliance of nurses with the standard

fall prevention protocol.

Data Analysis

For the qualitative data, systematic method of analysis will be done. After gathering

lifeworld descriptions of personal experiences, each account will become a “text” that is ready

for analysis of meanings and for the formulation of these meanings into a coherent story of

interrelated themes and insights. Systematic method of analysis in the qualitative part will

include:

• Reading to get a narrative sense of the text as a whole

• Dividing the text into “meaning units” that discriminate changes in the

meaning

• Expressing the meanings in more transferrable and general ways

• Formulating a narrative structure that highlights and integrates the

essential meanings of the experiences across cases

29
 • Illustrating the common themes in greater detail by elaborating further

and also by using quotations from the research respondents’ original

descriptions.

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http://www.nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/Patien
tSafetyQuality/Research-Measurement/The-National-Database/Nursing-Sensitive-
Indicators_1.aspx

Dunton, N., Gajewski, B., Taunton, R. L., & Moore, J. (2004). Nurse staffing and patient falls
on acute care hospital units. Nursing Outlook, 52(1), 53-59. doi:DOI:
10.1016/j.outlook.2003.11.006

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?[article]. Journal ofNursing Administration,
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Grenier-Sennelier C, Lombard I, Jeny-Loeper C, et al. (2002). Designing adverse event

prevention programs using quality management methods: the case of falls in hospital. Int J
Qual Health Care. Oct;14(5):419–26.

Gutierrez, F., & Smith, K. (2008). Reducing falls in a definitive observation unit. CriticalCare
Nursing Quarterly, 31(2), 127-139. Retrieved from SCOPUS database.

Hendriks, M. R. C., Bleijlevens, M. H. C., van Haastregt, J. C. M., de Bruijn, F. H., Diederiks,
J. P. M., Mulder, W. J., et al. (2008). A multidisciplinary fall prevention program for elderly
persons: A feasibility study. Geriatric Nursing,29(3), 186-196. doi:DOI:
10.1016/j.gerinurse.2007.10.019

Huey-Ming Tzeng, & Chang-Yi Yin. (2008). Nurses' solutions to prevent inpatient falls in
hospital patient rooms. Nursing Economics, 26(3), 179-187. Retrieved from SCOPUS
database.

Isomi, M., et. al (2013). Preventing In-Facility Falls. Making Health Care Safer II: An Updated
Critical Analysis of the Evidence for Patient Safety Practices. NBCI. Chapter 19. Retrieved
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Kaplow, R. (2003). AACN synergy model for patient care: A framework to optimize outcomes.
Critical Care Nurse, 23, 27-30. Retrieved from SCOPUS database. McEven, M., & Wills, E.M.
(2007). Theoretical basis for nursing (2nd ed.) Philadelphia:Lippincott Williams & Wilkins.

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Meade, C. M., Bursell, A. L., & Ketelsen, L. (2006). Effects of nursing rounds: On patients'
call light use, satisfaction, and safety. American Journal of Nursing,106(9), 58-70. Retrieved
from SCOPUS database.

Morse, J. M., Black, C., Oberle, K., & Donahue, P. (1989). A prospective study to identify the
fall-prone patient. Social Science & Medicine, 28(1), 81-86. doi:DOI: 10.1016/0277-
9536(89)90309-2

Morse, J.M., (1993). Nursing Research on patient falls in health care institutions. Annual
Review of Nursing Research 11, 299-316.Morse, J.M., (2009). Preventing patient falls:
Establishing a fall intervention program (2nd ed.). New York: Springer Publishing

Murphy, T. H., Labonte, P. B. C., Klock, M., & Houser, L. (2008). Falls prevention for elders
in acute care: An evidence-based nursing practice initiative. Critical CareNursing Quarterly,
31(1), 33-39. doi:10.1097/01.CNQ.0000306394.79282.95

Oliver D, Healey F, Haines TP. (2010). Preventing falls and fall-related injuries in
hospitals. Clin Geriatr Med. Nov;26(4):645–92

Polit, D.F., & Beck, C.T., 2004. Nursing research: Principles and methods (7th ed.)

Philadephia, PA: Lippincott Williams & Wilkins. 38

Rush, K. L., Robey-Williams, C., Patton, L. M., Chamberlain, D., Bendyk, H., & Sparks, T.
(2009). Patient falls: Acute care nurses' experiences. Journal of ClinicalNursing, 18(3), 357-
365. Retrieved from CINAHL database.

Scott, V., Votova, K., Scanlan, A., & Close, J. (2007). Multifactorial and functional mobility
assessment tools for fall risk among older adults in community, homesupport, long term and
acute care settings. Age & Ageing, 36(2), 130-139. Retrieved from CINAHL database.

The American heritage dictionary of the English language, (4th ed.). (2003). Houghton Miflin
Company. Retrieved from http://www.thefreedictionary.com/compliance

The Joint Commission for Accreditation of Health Care Organizations (2009a). National
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NationalPatientSafetyGoals

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Appendix A. Letter to the Administration

May 23, 2016

Greetings of Peace!

I am a graduate school student in the Master of Arts in Nursing Program of Far Eastern
University major in Medical Surgical Nursing. I am currently conducting a study
entitled:“NURSES’ COMPLIANCE AND EXPERIENCES WITH FALL PREVENTION
PROTOCOL”. This will highlight the compliance on fall prevention measures of the staff
nurses from all the nursing units and their experiences associated with complying. In line with
this, I would like to ask your permission to allow the researcher to collect data from the
aforementioned general unit in the hospital. I will be conducting chart and environmental

32
reviews and will be interviewing nurses in the general unit depending on their availability and
free will. Data collection period will be on June 16 to August 25, 2016.

Rest assured that the respondents’ anonymity and confidentiality is secured. For further
inquiries contact me at your most convenient time at (+639)256016433.Thank you for your
assistance in this academic endeavor.

Respectfully Yours,

MAN Graduate Student

Far Eastern University
Staff Nurse 3MainB-ASU

Noted by:

Research Adviser

Approved by:
Dean, Institute of Nursing Graduate Studies

Appendix B. Rounding Tool for patients identified at high risk for falls

Modified Rounding Tool for patients identified at high risk for falls

Instruction: Complete one form on each high risk patient in the department on the day of the
audit.

Sign on door/ Kilroy Instruction in ID band ON Fall brochure given

Sign communication
board: Call for
assistance

1= Yes 1= Yes 1= Yes

1= Yes 2= No 2= No 2= No
2= No

Call bell, patient Environment free Side rails raised and Was patient or
belongings within from clutter? bed on lowest family educated?
reach position? Look for charting.

1= Yes 1= Yes 1= Yes 1= Yes

33
 2= No 2= No 2= No 2= No

Fall on this admission? Charted Hourly Rounds for Nursing Care Plan
appropriate risk Fall form for High Risk for
level using Morse accomplished? Fall Patients
Scale?

1= Yes 1= Yes 1= Yes 1= Yes

2=No 2= No 2= No 2= No

Fall Risk Reassessment PT/OT order and Nurses Notes on

Form accomplished? gait assessment High Risk for Fall TOTAL SCORE:
documentation if patients
applicable
_______
1= Yes
1= Yes 2= No 1= Yes
2= No N/A 2= No

Appendix D. Fall Prevention Protocol

I. Title:

Fall Prevention Protocol

II. Definition of Terms:

Fall- a sudden, uncontrolled, downward displacement of the body to the ground or

other object, excluding falls resulted from violent blows or other purposeful actions.

III. Coverage:

This policy shall apply to all groups and departments admitting, providing services,

and giving care to patients.

34
IV. Protocol Inclusion:

Morse Scale- accomplished on the day of admission to identify patients who are at

high risk for fall. (Please see Appendix D.1)

Fall Brochure- given by the admission office and admitting nursing units to patient

and/or relatives; includes ways to avoid fall incidence, translated in layman’s terms.

(Please see Appendix D.2)

Hourly Rounds for Fall- accomplished by nurses every hour at every shift, every

day, to document their interventions rendered during their hourly rounding on the

patient. (Please see Appendix D.3)

Fall Risk Reassessment Form- accomplished by the receiving nurse to reassess

the patient’s fall risk every 7 days, or when deemed necessary (i.e. when the patient

undergone procedure requiring sedation, surgical operation putting the patient on

anesthesia, a change in medication list, or if the patient has been transferred from

one unit to another). (Please see Appendix D.4)

Patient and Family Education Form- a form accomplished by the

multidisciplinary team to document their health teachings.

Nursing Care Plan- accomplished by the nurses to indicate their plan of

management for patients at high risk for fall.

Nurses’ Notes- documentation of nurses’ for patients at high risk for fall,

everything that transpired significantly during the shift, their interventions, and

condition of patient upon endorsement; it is written on the Multidisciplinary

Progress Notes.

35
 PT/OT Notes- for patients having gait training, standing/balance training, a

documentation of Physical/Occupational Therapists are required to be written in the

Multidisciplinary Progress Notes.

Kilroy Sign- the signage used by the hospital to indicate that the patient is at high

risk for fall; it is posted outside the door of the patient’s room. (Please see Appendix

D.5)

Call bell and other patient belongings within reach- ensures that everything the

patient needs are within his/her reach so as to avoid reaching/leaning towards that

might contribute to fall.

Fall Committee- consists of a nurse manager and staff nurses who are geared

towards eradicating fall incidents in the hospital. They review, revise, and formulate

interventions and policies for continuous attempt to eradicate fall in the hospital.

Appendix D.1

MORSE SCALE

36
Appendix D.2

FALL BROCHURE

37
Continuation...

38
Appendix D.3

HOURLY ROUNDS FOR FALL FORM

39
Appendix D.4

FALL RISK REASSESSMENT FORM

40
Appendix D.5

KILROY SIGN

41
Appendix E. Clustering Assignment of Nursing Units

1. Medical Surgical Cluster

a. Medical Surgical 1

• 1 West- Geriatric

• 5 Main A- Cancer

• 5 West- Cancer

b. Medical Surgical 2

• 2 Annex- Orthopedic

• 2 East- General Cases

• 5 Annex- General Cases

42
 • 6 Main A- Pulmonary

c. Medical Surgical 3

• 2 Main A- Cardiovascular

• 2 West- Cardiovascular

• G West- Cardiovascular

• 3 Annex- Digestive and Liver

2. Maternal and Child Cluster

a. 2 Main B- Obstetrics and Gynecology

b. 3 Main A- Pediatrics

c. 3 West- Medical Pediatrics

d. NICU- Neonatal Intensive Care

e. PICU- Pediatric Intensive Care

3. Intensive Cluster

a. 3 Main B- Neuroscience

b. ASU- Acute Stroke Unit

c. JDICU- Medical Intensive Care Unit

d. NCCU- Neuro Critical Care Unit

e. CCU- Coronary Care Unit

43