Patient perceptions and experiences with falls during hospitalization and after discharge

Applied Nursing Research 31 (2016) 79–85

Contents lists available at ScienceDirect

Applied Nursing Research
journal homepage: www.elsevier.com/locate/apnr

Original Article

Patient perceptions and experiences with falls during hospitalization and
after discharge
Clayton Shuman, MSN, RN a, Jia Liu, MSN a, Mary Montie, PhD a,⁎, Jose Gabriel Galinato, MSN, RN a,
Molly A. Todd, MS, RN b, Marcia Hegstad, RN, MN b, Marita Titler, PhD, RN a
a
b

University of Michigan, School of Nursing, Ann Arbor, MI 48109, USA
St. Joseph Mercy-Ann Arbor, Ann Arbor, MI 48106, USA

a r t i c l e

i n f o

Article history:
Received 5 November 2015
Revised 19 January 2016
Accepted 28 January 2016
Available online xxxx
Keywords:
Falls
Fall prevention

Discharge instructions
Older adults
Perceptions

a b s t r a c t
Aims: The aim of this study was to describe hospitalized older adults' (N 60 years) perceptions about (1) their fall
risks while hospitalized; (2) fall prevention interventions received while hospitalized; and (3) fall prevention
discharge instructions.
Background: Little is known about hospitalized older adults' perceptions regarding fall prevention interventions
received during hospitalization and fall prevention discharge instructions.
Methods: This is a prospective, exploratory study using qualitative methods.
Results: This paper reports qualitative findings of patients' perspectives on fall prevention interventions during
hospitalization and at discharge. Eight major themes supported by multiple minor themes emerged: overall perceptions of falling; overall perceptions of fall prevention interventions while hospitalized; “telling” fall prevention; “doing” fall prevention; effectiveness of fall prevention strategies; personal fall prevention strategies; fallrelated discharge instructions; and most effective fall-related discharge instructions.
Conclusions: Findings suggest healthcare providers need to more fully engage patients and families in understanding fall prevention interventions and factors contributing to falls during hospitalization and at discharge.
© 2016 Elsevier Inc. All rights reserved.

Falls are a significant problem for older adults, particularly for those
who are hospitalized (Clyburn & Heydemann, 2011; Milisen et al.,
2013). Falls are among the most frequently reported patient safety incidents, accounting for approximately 40% of all adverse events in hospitals (Miake-Lye, Hempel, Ganz, & Shekelle, 2013; Oliver, 2008).
Moreover, up to 50% of inpatient falls result in some sort of injury
(e.g., fracture, trauma, and death) (Oliver, Healey, & Haines, 2010;
Tinetti & Kumar, 2010). Falls can also contribute to patient anxiety,
loss of confidence in mobility and activities, social isolation, prolonged hospital stay, discharge to long-term care facilities, and increased healthcare
cost (Miake-Lye et al., 2013; Oliver, 2008; Tinetti & Kumar, 2010).
Efforts to reduce falls in hospitals have largely focused on conducting
routine fall risks assessments followed by implementing general fall
prevention interventions for those at risk (Oliver, 2008; Oliver et al.,
2010). In addition to these system- and clinician-driven efforts, fall prevention must involve other members within the context of care, including patients and their families. Perceptions (e.g., beliefs and awareness)
about an individual's health are essential to engage people in understanding their health risks, as well as, in adopting behaviors to reduce
those risks (Garces et al., 2012; Mullins, Abdulhalim, & Lavallee, 2012;

⁎ Corresponding author at: University of Michigan, School of Nursing, 400 N. Ingalls,
Suite 4170, Ann Arbor, MI 48109, USA.
E-mail address: (M. Montie).
/>0897-1897/© 2016 Elsevier Inc. All rights reserved.

Shubert, Smith, Prizer, & Ory, 2014). However, minimal research has addressed hospitalized older adults' perceptions about their fall risks, interventions they received to prevent falls, and discharge instructions
to reduce falls. Therefore, it is imperative to understand older adults'
perceptions of falls and fall prevention interventions to fully engage
them in the adoption of behaviors that will reduce falls during hospitalization and after discharge to more effectively address this national patient safety issue.
The specific aims of this exploratory study were to describe hospitalized
older adults' (≥60 years) perceptions about (1) their fall risks while hospitalized; (2) interventions they received to prevent falls while hospitalized;
and (3) the instructions received at discharge to prevent falls at home.
1. Background
Previous studies have explored perceptions regarding falls and fall
prevention, but most have focused on community-dwelling older adults
rather than those who are hospitalized (Boyd & Stevens, 2009; Calhoun
et al., 2011; Faes et al., 2010; Høst et al., 2011; Karlsson, Vonschewelov,
Karlsson, Cöster, & Rosengen, 2013; Laing, Silver, York, & Phelan, 2011;
McInnes, Seers, & Tutton, 2011; McMahon, Talley, & Wyman, 2011; Roe
et al., 2009). Findings from these studies demonstrate that older adults:
(1) believe falling to be a normal part of the aging process (Høst et al.,
2011; McInnes et al., 2011); (2) consider falls embarrassing and have


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a fear of falling (Boyd & Stevens, 2009; Roe et al., 2009); and (3) restrict
or stop normal activities to prevent falling (Roe et al., 2009). Findings

from these studies have also been used to guide development, testing,
and implementation of community-based fall prevention programs
(Baker, Gottschalk, & Bianco, 2007; Tinetti et al., 2008).
In contrast to findings from community settings, little is known
about perceptions of hospitalized older adults regarding their fall risks,
despite patient education being frequently used to prevent falls (Ang,
Mordiffi, & Wong, 2011). Carroll, Dykes, and Hurley (2010) interviewed
nine patients who had fallen while hospitalized and found that most
were not aware of their risk of falling; those who were aware received
inconsistent messages from nurses regarding their fall risks. Patients
stated that they “wanted to be informed of why they were at risk and
what specific activities the nurse wanted them to do to reduce their
risk for falling, and the role of the healthcare team in their fall prevention.” (Carroll et al., 2010; page 240). Similarly, findings by Rogers
(2013) demonstrated that adult inpatients had little information
about their fall risks.
Falls are among the most frequently occurring post-discharge adverse
events (Tsilimingras & Bates, 2008), and the incidence of falls in the postdischarge period is more than in the general community population
(Davenport et al., 2009). The significance of discharge instruction has
been demonstrated when older adults are equipped with knowledge regarding self-care following hospital discharge (Bobay, Jerofke, Weiss, &
Yakusheva, 2010; Foust, Vuckovic, & Henriquez, 2012; Maloney &
Weiss, 2008). However, only one study of 333 subjects, conducted in
Australia, examined older adults' perceptions about fall prevention strategies after discharge and found that many had little knowledge about appropriate strategies to prevent falls at home (Hill et al., 2011).
Understanding patients' perceptions about fall risks and interventions to prevent falls is critical to advance the knowledge of preventing
falls during and following hospitalization. This study provides insights
about this important area from the perspective of the patients.
2. Method
This prospective exploratory study was conducted in a 450-bed community hospital located in Michigan. Informants were recruited from two
adult medical–surgical units. Approval of the Institutional Review Board
from the University of Michigan and the study site was obtained.
2.1. Design

A prospective exploratory design using qualitative methods was
conducted to meet the study aims. To solicit participant perceptions,
two semi-structured interview guides were developed with openended questions and probes. The guides were designed to be delivered
verbally. The first interview guide was delivered face-to-face while informants were hospitalized to elicit information about their perceptions
regarding falls prior to hospitalization, risk for falling in the hospital, and
fall prevention interventions they received while hospitalized. The second interview guide was delivered over the telephone after informants
were discharged to their homes to obtain additional information about
fall prevention interventions used in the hospital, and instructions that
they received at discharge to prevent falls at home.
2.2. Sample
To be eligible for the study, potential informants had to meet the following inclusion criteria: (1) 60 years of age or older; (2) hospitalized
on the study unit for at least 48 hours; (3) at risk for falls as defined
by nursing staff via the Morse Score within 24 hours prior to the interview; (4) have a working phone number at home; (5) be medically stable; and (6) speak English. Informants were excluded if they were
acutely confused (e.g., delirious) as determined by the Confusion

Assessment Method (CAM) screening tool, which was administered
prior to seeking informed consent.
Eighteen informants were enrolled in the study, with fifteen completing the post-discharge interview. We were unable to reach one informant using the telephone number they provided during the first
interview; the other two were not discharged to their homes. Ten informants were male, and five were female. The mean age was 72 years
(SD = 10.86). Informants were contacted by telephone within 3 days
after discharge to set up a time for the post-discharge interview. All
post-discharge interviews were conducted within 8 days after discharge, with the majority completed within 4 days.
2.3. Data collection procedures
The list of potential informants was provided by a clinical nurse specialist and nurse manager of the study units to the investigative team
each day for review. After validation that potential informants met
study inclusion criteria, they were approached in their hospital rooms.
Ten eligible informants declined to participate. If a potential informant
was not diagnosed with delirium in accordance with the CAM, written
informed consent was obtained prior to any study procedures. A trained
research assistant who was a part of the research team conducted inhospital and post-discharge interviews. The in-hospital interview was

conducted in the patient's hospital room without the presence of
healthcare providers or other patients and was audio recorded. During
the hospital interviews, informants were asked about their perspectives
concerning their risk for falling while in the hospital, and interventions
they received during hospitalization to prevent falls. Interviews were
45 minutes or less. At the end of the interview, informants provided a
home telephone number for contact following discharge.
After informants were discharged from the hospital, they were
contacted within 3 days via telephone to schedule an interview about
their perceptions on interventions they received in the hospital to prevent falls, as well as, discharge instructions they received about prevention of falls at home. All post-discharge interviews were conducted
within 8 days after discharge via telephone, were audio recorded, and
lasted no more than 45 minutes.
2.4. Data analysis
All of the interviews were transcribed verbatim and reviewed for
transcription accuracy. Transcribed interviews were analyzed using
the constant comparative methods of Glaser and Strauss (Corbin &
Strauss, 1990; Glaser & Strauss, 1967). To ensure appropriate, rigorous,
and robust data analysis, three members of the investigative team with
expertise in qualitative analysis individually performed initial coding
(e.g., minor themes). Minor themes were then compared, discussed,
and agreed upon. Individually, the three investigators organized the
minor themes into major themes. Major themes were then compared
and discussed until a consensus was reached.
3. Results
Qualitative data analysis revealed eight major themes: (1) overall perceptions of falling; (2) overall perceptions of fall prevention interventions
while hospitalized; (3) “telling” fall prevention; (4) “doing” fall prevention; (5) effectiveness of fall prevention strategies; (6) personal fall prevention strategies; (7) fall-related discharge instructions; and (8) most
effective fall-related discharge instructions. Multiple minor themes support each of these major themes, and are discussed below.
3.1. Overall perceptions of falling
The major theme, overall perceptions of falling, is supported by three
minor themes, including past fall experiences, fall risks, and fear of fallrelated injuries.

C. Shuman et al. / Applied Nursing Research 31 (2016) 79–85

3.1.1. Past fall experiences
Most informants perceived that they had indeed experienced one or
more falls prior to their current hospitalization. Not only did informants
experience one or more falls, but that they also perceived the reasons
for these falls:

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3.2.2. Tailored fall prevention interventions
A number of informants shared that the fall prevention strategies they
received during hospitalization were specific to their healthcare needs:
“…Well, I think they were designed specifically for my problems, which
was herniated discs, and the surgery that I had…”

“…Because I have a lack of balance…I lost balance…”
“…Dehydration and low blood pressure…”
Other reasons noted by informants that contributed to their falls included other health conditions (e.g. brain tumor, herniated disc), not paying attention to their surroundings, and medications they were taking.
3.1.2. Fall risks
It is noteworthy that despite being currently designated as fall risks
by healthcare providers, as well as having experienced prior falls, most
informants stated that they did not believe they were at risk for falling
while in the hospital:
“…No, because there is enough people around when I get up go to the
bathroom. They all helped me…”
“…I′m not necessarily concerned about falling because the hospital
staff…they have a belt on me. So, I′m not worried about that…”

The majority of the informants felt safe due to the presence of
healthcare providers and the healthcare they received, which led
them to trust their healthcare providers (e.g., nurses).
3.1.3. Fear of fall-related injuries
Despite the apparent trust the informants had with their healthcare
providers, they were concerned about potential injuries that could result from a fall while they were hospitalized:
“…I guess break a bone. I have osteoporosis…”
“…That I will break hip and be in the hospital as I were in the midst of
having the cancer, and I live alone, so it′s very hard for me…”
As in other issues with the elderly, their fear of falling is one of several issues that is compounded by other health conditions and living arrangements experienced by older adults.
3.2. Overall perceptions of fall prevention interventions while hospitalized
Interviews conducted during and after discharge asked the informants to share their perceptions about what was done to prevent falls
while they were hospitalized. These interviews resulted in four minor
themes, described below, to support this major theme, overall perceptions of fall prevention interventions while hospitalized.

“I would say the reminder [was specific to me], like I am a bare-footed
person all the time around the house and everything, a reminder of putting socks on every time I got up was beneficial to me…”

3.2.3. General fall prevention interventions
Other informants, however, perceived that all patients received the
same general fall prevention interventions:
“Yes, I think they [all patients] were told the same things…”
“I don′t think they [fall prevention strategies] were specifically for me,
they were pretty general…”

3.2.4. Overall satisfaction of fall prevention interventions
Informants shared thoughts on whether their healthcare providers
could have contributed more to their fall prevention:
“…No, they are pretty thorough. Yeah, they are pretty much focusing on
your problems and your situation, and try to give you the best…”

“…I′m pretty sure that the people that [are] working in the hospital are
pretty good at instructing their patients. And I know me and probably a
lot of other patients tend to be a little stubborn, or we press the call button, and they′re busy, and they can′t come right away, so we decide to
get up and try something on our own…”
Although informants initially expressed that they did not receive information to prevent falls while they were hospitalized, as the interviews proceeded, and with use of interview probes, informants were
able to give examples of healthcare providers' actions that were utilized
to prevent them from falling. Some informants thought the interventions were specific to their needs, while others thought the interventions were more general and the same for all patients. The kinds of fall
prevention interventions that were received during hospitalization are
further described in the following two major themes: “telling” fall prevention and “doing” fall prevention.
3.3. “Telling” fall prevention
Informants described what their healthcare providers were “telling”
them in regard to how they could reduce their risk of falling while hospitalized. They discussed three fall prevention areas: (1) reminders;
(2) clearing obstacles; and (3) general assistance.

3.2.1. Non-acknowledgement of fall prevention interventions
Initially, informants stated that healthcare providers had not had
conversations with them about falls:

3.3.1. Reminders
Informants stated that their healthcare providers discussed some
general reminders in regard to fall prevention:

“I don′t think they′ve talked about falling, but they′ve taught [me] how
to get into the bed and out of the bed. They trained me how to do it,
which I assume is to prevent falling…”

“They said do not get up by myself…They just say go slow and made sure that at
least one of them [nurse] is in the room, and they took good care of me…”
“…Always reminding me to put my slippers on, or my socks on.”

“…Uh, I don′t know if they have actually told me anything about falling.”
However, as the conversation proceeded, informants started
discussing fall prevention interventions performed by healthcare providers and their satisfaction with these interventions.

3.3.2. Clearing obstacles
Informants explained that their healthcare providers had also engaged them in conversations about clearing obstacles:


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“…[They make sure the] floor is clear of obstacles, and they make sure
that, if you have any cause for them [obstacles] to think you might fall,
they won′t let you move, unless there′s somebody with you…”
“…obstacles that may, you know, be in your way, remove them or slide
them over from where your walking path would be....”

to make sure that there′s help available very quickly as you
need it…”
In many cases, informants' personal perceptions of the most effective fall prevention strategies were the same strategies that had been
provided by healthcare providers in the hospital.
3.6. Personal fall prevention strategies

3.3.3. General assistance
Informants also described general assistance that was inclusive of
fall prevention. For example, they commented on assistance with ambulation and mobility:
“Well they told him all those techniques…how to get into the bed and
not fall back…or how to hold on to the walker. How to turn, not twist.
All of the things that you need to know in order to successfully move

around without damaging yourself”
“…I know this afternoon, they want to put me in a chair, and that I will
be getting a lot of help for that…”

3.4. “Doing” fall prevention
After informants clarified what healthcare providers were “telling” them
about fall prevention while they were hospitalized, they then discussed
what their healthcare providers were “doing” with regard to fall prevention.
Informants indicated that healthcare providers were “doing” several things,
such as teaching fall prevention and providing physical assistance.
3.4.1. Teaching
Informants explained that their healthcare providers gave them a
great deal of instruction regarding fall prevention:
“…They teach me move slowly, you can raise up, and so I get my chest
up and swing my feet a little bit slowly…”

Patients' perceptions about ways to reduce their own risk of falling
are important, since they depict how patients view themselves as at
risk for falls. The study informants remarked that they thought becoming more proactive and acquiring better awareness of their surroundings would assist them in reducing their own risks for falls.
3.6.1. Being proactive
Informants stated that one way in which they thought they could
lessen their fall risks was by becoming more proactive, by paying
more attention to their fall risks, and by following the advice of their
healthcare providers:
“…Uh, probably the biggest thing would be to pay attention…And understand the seriousness of it [falling]…”
“…I think people have to be better judges of what they can really do…”

3.6.2. Acquiring awareness of surroundings
Informants also stated that another way to reduce their risks for falling was to become more aware of their surroundings:
“…I can see certain things, like design of furniture, design of doorways,

design of height of furniture…I feel a lot of attention should be applied
for older people…”
“…if you got throw rugs, you don′t want those around because you
could stumble over them.”

“Well, they teach me how to stand and lean…Just get my balance, so I
don′t fall. And they give me a lot of support and encouragement…”
3.7. Fall-related discharge instructions
3.4.2. Physical assistance
Informants also indicated that they received physical assistance for
fall prevention. This included a variety of activities, such as assistance
with mobility (e.g., utilization of a walker), belt security, and chair/sitting assistance.

During the post-discharge interviews, informants shared information they received at discharge that focused on preventing falls at
home. This major theme, fall-related discharge instructions, is supported by two minor themes described below.

“…Well, when I walked, they had a belt around me, and somebody back
of me, following along, with a grip of the belt…”

3.7.1. Initial perceptions of fall-related discharge instructions
Informants discussed discharge directions, specifically with regard
to fall prevention:

“…Well, they′ve been very kind about lifting me out of the chair on the
commode, and rolling me in there, rolling me up to the sink, so I can
wash my face.”

“…There wasn′t any discussion of that… You know frankly, I didn′t
think about that.”
“I don′t believe I was told anything.”

3.5. Effectiveness of fall prevention strategies
Informants went on to share their perceptions about the effectiveness of the fall prevention interventions on the basis of their personal
conditions and own experiences.
“I guess my walker will be the most effective…”
“Well, I think they make sure that in the room or wherever I
am, that there are as few obstacles as possible. And that they try

Over half of the informants did not initially perceive that they had
received discharge instructions about fall prevention. However, further
interview probes with these informants revealed that they had indeed
received discharge instructions regarding fall prevention.
3.7.2. Verbal and written discharge instructions
Informants elaborated that healthcare providers not only verbally
delivered fall prevention instructions about the physical environment
and mobility, but also provided a fall prevention pamphlet and other
written information.


C. Shuman et al. / Applied Nursing Research 31 (2016) 79–85

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3.7.3. Physical environment
Informants stated that conversations at discharge included specific
fall prevention concerning physical environment:

“…Clear the area of debris…And um keep everything organized and
structured and you′d have no problems of walking around…”

“I was interviewed by the case manager, and she was very interested in
the layout of my home, as far as entrances, exits, um that had something
to do with falling…”

“…Watch out for area rugs that are sticking out the corner. Either nail
them down or remove them from the room, if it′s an area rug that has
tilted upwards…”

“…In the bathroom, always have a rubber mat in the tub, and some rug
that′s for a bathtub, water resistant, a rug outside of the tub, so when
you step out, your risk for falling would be reduced by that too…”

Informants acknowledged that the fall prevention instructions they
received at discharge addressed both physical and environmental effects. Informants were eager to discuss these fall prevention strategies,
and most informants stated that the information they had received regarding fall prevention was helpful.

3.7.4. Mobility
Mobility discussions were also expressed by the informants:
“…They went through a lot of suggestions…They′ve offered a pretend
car and they showed you ways to get in and out…”
“…First of all, I′m not supposed to make fast moves, fast turns, sharp
turns. I was supposed to move very slowly. I was not supposed to do it
on my own. I should be using a walker or be with someone…”

3.7.5. Written discharge instructions
Informants shared that they also received written information
(e.g., pamphlets) regarding fall prevention:
“…There were sheets, there were copies that were given me to discuss
some of this stuff [fall prevention]…”
“…They gave me, you know, a lot of, you know, books and pamphlets,

and lists and that. And that was very, very helpful…”
Although informants initially responded that they had not received
discharge instructions, they were able to share that they did receive
both verbal and written information about prevention of falls at home.
Informants also shared their perceptions about the effectiveness of the
discharge instructions as described below.
3.8. Most effective fall-related discharge instructions
According to informants, the most effective fall prevention instructions included both physical and environmental strategies.
3.8.1. “Physical” fall preventions
Informants discussed several fall prevention instructions that aided
them physically:
“The three-point stance. I always have three points of… before you
move, get balance as much as possible, don′t try to stretch out, or reach,
or do more than you can…”
“You know they taught you how to sit up. They said don′t twist, or roll.
Just getting yourself in a sitting position those few days after surgery
was work. And they were very helpful with that…”
Informants reported not only that they received adequate instruction, but also that they were “shown” how to physically prevent falls.
3.8.2. “Environmental” fall preventions
Informants also stated the fall prevention instructions at hospital
discharge included environmental advice:

4. Discussion
Findings from this exploratory study revealed that most informants
had fallen one or more times prior to hospitalization, and that most
knew what had contributed to their falling (e.g., loss of balance).
These reasons suggest a similarity to other studies that have reported
balance as a contributing factor for falls in older adults (Carroll et al.,
2010; Huang et al., 2012; Talbot, Musiol, Witham, & Metter, 2005;
Zecevic, Salmoni, Speechley, & Vandervoort, 2006). Despite acknowledgement of experiencing a fall, informants were not aware that they

were at risk for falls while hospitalized. Informants did, however, freely
express their fear of falling and potential injuries (e.g., broken bone, broken hip) while they were hospitalized. These findings are similar to
other studies in which patients have a fear of falling during hospitalization because they are frail and have poor functional reserve
(Mackintosh, Hill, Dodd, Goldie, & Culham, 2006; Oliver et al., 2010).
Although informants did indeed receive fall prevention interventions while hospitalized, they initially did not perceive these interventions as such. After further discussion (e.g., probing), informants
commented on various conversations and actions that their healthcare
providers initiated regarding fall prevention. Examples include what
their healthcare providers were “telling” them (e.g., reminders, clearing
obstacles, and general assistance), and what healthcare providers were
“doing” to assist them (e.g., teaching and physical assistance). In subsequent conversations, informants stated that they were not only satisfied
with these fall prevention interventions (e.g., “…they were very thorough” and “…are pretty good at instructing patients…”), but also that
some felt they received fall prevention interventions tailored to them
(e.g., “…designed specifically for me…”). The acknowledgement of tailored fall prevention interventions is congruent with recommendations
that these interventions should be tailored to patient-specific fall risk
factors (Cameron et al., 2012; Coussement et al., 2008; Hempel et al.,
2013; Kenny et al., 2011; Oliver et al., 2010). Informants felt that these
actions (e.g., fall prevention interventions) were effective.
Likewise, informants did not initially perceive that they had received
fall prevention interventions at discharge. After further probing, informants reported that they had not only received verbal discharge fall
prevention instructions with regard to the physical environment and
mobility, but they had also received written information about
preventing falls (e.g., sheets, books, and pamphlets).
In addition, informants discussed their perceptions regarding the
most effective fall prevention discharge instructions that they received.
These perceptions included both physical (e.g., three-point stance and
body positioning), and environmental strategies (e.g., clearing areas of
debris and rug placement). These perceptions parallel the work of Hill
et al. (2011), as these strategies were also identified by patients as
post-discharge fall prevention strategies.
It is important to note that informants initially did not perceive that

they were at risk for falls or received interventions to prevent falls during hospitalization and at discharge. However with further probing, and
as the interviews progressed, the informants clarified their perceptions
and described fall prevention interventions they received. These initial


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C. Shuman et al. / Applied Nursing Research 31 (2016) 79–85

perceptions by informants suggest that patients may not be mindful of
their risk for falls, and perceive that the healthcare team will keep
them safe. Additionally, these initial perceptions about their fall risks
and interventions they received to prevent falls suggest that healthcare
providers' level and type of engagement with patients and families regarding understanding their fall risks, and interventions to prevent
falls has significant room for improvement.
4.1. Limitations
Our study consisted of a single hospital setting, which only accounts
for patients' perspectives from that site. Although findings may not be
generalizable beyond the current setting, we do acknowledge the
value of replicating this study at multiple sites, since patient perceptions
of fall interventions are important for fall prevention. Further research is
needed in multiple sites to support these findings.
4.2. Implications for research
This study should be replicated as a multi-site study representing
different geographic regions of the country. Future research should
also include interviews of family members in addition to patients, as
well as the healthcare providers delivering care. Preventing falls in hospitals is a collaborative mission that requires the participation of patients and family members. Thus, further research is needed to
understand how healthcare providers can more effectively engage patients and family members in prevention of falls during hospitalization
and following discharge.
4.3. Implications for clinical practice

There are several implications for practice from this study. First,
nurses and other healthcare providers in hospital settings need to do
more than impart information, but rather have conversations with hospitalized patients and their families about why they are at risk for falling, and define the specific fall risk factors they have that may
contribute to a fall or injury from a fall. Second, having repeated conversations with patients and family members about what they can contribute (e.g., paying more attention; heeding advice of the healthcare team)
to prevent falls is also warranted. Lastly, nurses should explain to patients and family members that fall prevention is a collaborative process, which necessitates the active participation of patients and their
family members in understanding their risks for falling and interventions to prevent falling.
5. Conclusion
This exploratory study revealed that informants received fall prevention interventions while hospitalized and at hospital discharge,
even though they did not perceive these as such initially. Further discussion and probing with informants led to this realization, as depicted by
informant accounts of detailed descriptions of actions, instructions, and
written and verbal fall prevention interventions. Undoubtedly, communication and level of engagement influenced patient perceptions. These
findings suggest that healthcare providers need to more fully engage
and provide clarity to patients and family members regarding fall risks
and fall prevention. With appropriate patient and caregiver engagement, fall prevention interventions can be effectively implemented,
without patient misconceptions.
References
Ang, E., Mordiffi, S. Z., & Wong, H. B. (2011). Evaluating the use of a targeted multiple intervention strategy in reducing patient falls in an acute care hospital: A randomized
controlled trial. Journal of Advanced Nursing, 67(9), 1984–1992.

Baker, D. I., Gottschalk, M., & Bianco, L. M. (2007). Step by step: Integrating evidencebased fall-risk management into senior centers. The Gerontologist, 47(4), 548–554.
Bobay, K. L., Jerofke, T. A., Weiss, M. E., & Yakusheva, O. (2010). Age-related differences in
perception of quality of discharge teaching and readiness for hospital discharge.
Geriatric Nursing, 31(3), 178–187.
Boyd, R., & Stevens, J. (2009). Falls and fear of falling: Burden, beliefs and behaviours. Age
and Ageing, 38(4), 423–428.
Calhoun, R., Meischke, H., Hammerback, K., Bohl, A., Poe, P., Williams, B., & Phelan, E. A.
(2011). Older adults' perceptions of clinical fall prevention programs: A qualitative
study. Journal of Aging Research, 2011.
Cameron, I. D., Gillespie, L. D., Robertson, M. C., Murray, G. R., Hill, K. D., Cumming, R. G., &
Kerse, N. (2012). Interventions for preventing falls in older people in care facilities

and hospitals. Cochrane Database of Systematic Reviews, 12.
Carroll, D. L., Dykes, P. C., & Hurley, A. C. (2010). Patients' perspectives of falling while in
an acute care hospital and suggestions for prevention. Applied Nursing Research,
23(4), 238–241.
Clyburn, T. A., & Heydemann, J. A. (2011). Fall prevention in the elderly: Analysis and
comprehensive review of methods used in the hospital and in the home. Journal of
the American Academy of Orthopaedic Surgeons, 19(7), 402–409.
Corbin, J., & Strauss, A. (1990). Basics of qualitative research: Grounded theory procedures
and techniques, 41, .
Coussement, J., De Paepe, L., Schwendimann, R., Denhaerynck, K., Dejaeger, E., & Milisen,
K. (2008). Interventions for preventing falls in acute and chronic care hospitals: A
systematic review and meta analysis. Journal of the American Geriatrics Society,
56(1), 29–36.
Davenport, R. D., Vaidean, G. D., Jones, C. B., Chandler, A. M., Kessler, L. A., Mion, L. C., & Shorr,
R. I. (2009). Falls following discharge after an in-hospital fall. BMC Geriatrics, 9(1), 53.
Faes, M. C., Reelick, M. F., Joosten-Weyn Banningh, L. W., Gier, M. d., Esselink, R. A., & Olde
Rikkert, M. G. (2010). Qualitative study on the impact of falling in frail older persons
and family caregivers: Foundations for an intervention to prevent falls. Aging &
Mental Health, 14(7), 834–842.
Foust, J. B., Vuckovic, N., & Henriquez, E. (2012). Hospital to home health care transition:
Patient, caregiver, and clinician perspectives. Western Journal of Nursing Research,
34(2), 194–212.
Garces, J. P. D., Lopez, G. J. P., Wang, Z., Elraiyah, T. A., Nabhan, M., Campana, J. P. B., ...
Pollard, S. (2012). Eliciting patient perspective in patient-centered outcomes research:
A meta narrative systematic review. Rochester: Mayo Clinic.
Glaser, B., & Strauss, A. (1967). The discovery of grounded theory: Strategies for qualitative
research. Chicago, IL: Aldine Transaction.
Hempel, S., Newberry, S., Wang, Z., Booth, M., Shanman, R., Johnsen, B., ... Ganz, D. A. (2013).
Hospital fall prevention: A systematic review of implementation, components, adherence, and effectiveness. Journal of the American Geriatrics Society, 61(4), 483–494.
Hill, A. -M., Hoffmann, T., Beer, C., McPhail, S., Hill, K. D., Oliver, D., ... Haines, T. P. (2011).

Falls after discharge from hospital: Is there a gap between older peoples' knowledge
about falls prevention strategies and the research evidence? The Gerontologist, 51(5),
653–662.
Høst, D., Hendriksen, C., & Borup, I. (2011). Older people's perception of and coping with
falling, and their motivation for fall-prevention programmes. Scandinavian Journal of
Public Health, 39(7), 742–748.
Huang, A. R., Mallet, L., Rochefort, C. M., Eguale, T., Buckeridge, D. L., & Tamblyn, R. (2012).
Medication-related falls in the elderly. Drugs & Aging, 29(5), 359–376.
Karlsson, M. K., Vonschewelov, T., Karlsson, C., Cöster, M., & Rosengen, B. E. (2013). Prevention of falls in the elderly: A review. Scandinavian Journal of Public Health, 41(5),
442–454.
Kenny, R., Rubenstein, L. Z., Tinetti, M. E., Brewer, K., Cameron, K. A., Capezuti, L., ...
Peterson, E. W. (2011). Summary of the updated American Geriatrics Society/British
Geriatrics Society clinical practice guideline for prevention of falls in older persons.
Journal of the American Geriatrics Society, 59(1), 148–157.
Laing, S. S., Silver, I. F., York, S., & Phelan, E. A. (2011). Fall prevention knowledge, attitude,
and practices of community stakeholders and older adults. Journal of Aging Research,
2011.
Mackintosh, S. F., Hill, K. D., Dodd, K. J., Goldie, P. A., & Culham, E. G. (2006). Balance score
and a history of falls in hospital predict recurrent falls in the 6 months following
stroke rehabilitation. Archives of Physical Medicine and Rehabilitation, 87(12),
1583–1589.
Maloney, L. R., & Weiss, M. E. (2008). Patients' perceptions of hospital discharge informational content. Clinical Nursing Research, 17(3), 200–219.
McInnes, E., Seers, K., & Tutton, L. (2011). Older people's views in relation to risk of falling
and need for intervention: A meta-ethnography. Journal of Advanced Nursing, 67(12),
2525–2536.
McMahon, S., Talley, K. M., & Wyman, J. F. (2011). Older people's perspectives on fall risk
and fall prevention programs: A literature review. International Journal of Older People
Nursing, 6(4), 289–298.
Miake-Lye, I. M., Hempel, S., Ganz, D. A., & Shekelle, P. G. (2013). Inpatient fall prevention
programs as a patient safety strategy: A systematic review. Annals of Internal

Medicine, 158(5_Part_2), 390–396.
Milisen, K., Coussement, J., Arnout, H., Vanlerberghe, V., De Paepe, L., Schoevaerdts, D., ...
Dejaeger, E. (2013). Feasibility of implementing a practice guideline for fall prevention on geriatric wards: A multicentre study. International Journal of Nursing Studies,
50(4), 495–507.
Mullins, C. D., Abdulhalim, A. M., & Lavallee, D. C. (2012). Continuous patient engagement
in comparative effectiveness research. JAMA, 307(15), 1587–1588.
Oliver, D. (2008). Evidence for fall prevention in hospitals. Journal of the American Geriatrics Society, 56(9), 1774–1775.
Oliver, D., Healey, F., & Haines, T. P. (2010). Preventing falls and fall-related injuries in
hospitals. Clinics in Geriatric Medicine, 26(4), 645–692.


C. Shuman et al. / Applied Nursing Research 31 (2016) 79–85
Roe, B., Howell, F., Riniotis, K., Beech, R., Crome, P., & Ong, B. N. (2009). Older people and
falls: Health status, quality of life, lifestyle, care networks, prevention and views on
service use following a recent fall. Journal of Clinical Nursing, 18(16), 2261–2272.
Rogers, L. M. (2013). Opening the black box: Understanding adult inpatient falls. Doctoral
dissertation Loyola University Chicago (Retrieved from />cgi/viewcontent.cgi?article=1682&context=luc_diss).
Shubert, T. E., Smith, M. L., Prizer, L. P., & Ory, M. G. (2014). Complexities of fall prevention
in clinical settings: A commentary. The Gerontologist, 54(4), 550–558.
Talbot, L. A., Musiol, R. J., Witham, E. K., & Metter, E. J. (2005). Falls in young, middle-aged
and older community dwelling adults: Perceived cause, environmental factors and
injury. BMC Public Health, 5(1), 86.

85

Tinetti, M. E., Baker, D. I., King, M., Gottschalk, M., Murphy, T. E., Acampora, D., ... Allore, H.
G. (2008). Effect of dissemination of evidence in reducing injuries from falls. New
England Journal of Medicine, 359(3), 252–261.
Tinetti, M. E., & Kumar, C. (2010). The patient who falls: “It's always a trade-off”. The
Journal of the American Medical Association, 303(3), 258–266.

Tsilimingras, D., & Bates, D. W. (2008). Addressing post-discharge adverse events:
A neglected area. Joint Commission Journal on Quality and Patient Safety, 34(2),
85–97.
Zecevic, A. A., Salmoni, A. W., Speechley, M., & Vandervoort, A. A. (2006). Defining a fall
and reasons for falling: Comparisons among the views of seniors, health care providers, and the research literature. The Gerontologist, 46(3), 367–376.