Despite the widespread use of fall risk prediction tools and hospital fall prevention programs,1 hospitalized patients continue to fall. Prior studies have found that 2% to 7% of all patients admitted to an acute care hospital sustained at least one fall during their hospitalization.2, 3 Moreover, fall rates will vary within a given hospital, with medical units tending to have higher rates and surgical units lower rates.2, 4Falls that occur during a patient's hospitalization have been associated with numerous adverse sequelae, including longer lengths of stay, fewer discharges to home, and increased health care costs.5, 6 Because falls have such an impact on patients, their families, and the organization, fall prevention is a major concern for hospitals and hospital systems.

Patients who sustain a fall in the acute care setting often exhibit one or more known fall risk factors. Reduced physical functioning or balance; lower extremity weakness; a new onset of delirium; polypharmacy; and the addition of new, known fall-inducing medications are all associated with a higher risk of falling during hospitalization.1, 7, 8 It stands to reason that there is also a cumulative effect, such that having more risk factors increases the likelihood of a fall.

Numerous fall prevention programs have attempted to reduce fall rates and lower fall risk among hospitalized patients, with limited success. In a recent Cochrane review, Cameron and colleagues examined studies of single and multifactorial fall prevention interventions conducted in care facilities and hospitals.9 Interventions included patient education, physiotherapy, medication review, bed alarms, bracelets to identify high-risk patients, and environmental modifications such as the type of flooring. Because of the low quality of the evidence, single interventions to reduce fall risk or fall rates yielded no firm conclusions. Multifactorial interventions showed a borderline reduction of fall rates, but there was no conclusive evidence that they reduced fall risk. The researchers reached only “uncertain” conclusions regarding the effects of fall prevention interventions on decreasing either fall rates or the risk of falling.

Yet despite our knowledge of fall risk factors and the widespread implementation of a variety of fall prevention programs, hospitalized patients often don't recognize that they are at risk for falling. Fall prevention programs often fail to address patient engagement, and this may affect patient adherence. Understanding the patient's perception of their fall risk and how this perception influences their intent to follow agreed-upon prevention measures is essential to reducing inpatient falls.

Purpose. The aim of this study was to describe patient perceptions of fall risk among hospitalized patients across four acute care specialty services.

METHODS

Design, setting, and sample. This observational, cross-sectional cohort study was conducted among a convenience sample of 100 patients admitted to a large midwestern academic medical center. A power analysis was performed to determine this sample size. The sample consisted of 25 patients from each of four service areas: medicine, neurology, oncology, and surgery. Patients were included if they had a Morse Fall Scale score greater than 45 and were alert and able to provide verbal consent. Patients were excluded if they were non-English speaking, had a neurological disease or injury that limited their ability to speak, had significant hearing loss with no access to hearing aids, or had severe dementia or an altered mental status such that they would be unable to understand the survey or communicate verbally. All participants provided verbal consent to participate. The study was approved by the organization's affiliated human research protection office before data collection began.

Data collection. Once verbal consent was obtained, a research team member asked each patient several questions about general demographics (age, gender, and race), the patient's reported fall history over the past year, and current and prior mobility status. The patient's hospital length of stay and most recent Morse Fall Scale score were obtained from the electronic health record.

Instruments. The Morse Fall Scale is a simple method for determining a patient's likelihood of falling based on six items: history of falls, presence of secondary diagnosis, use of ambulation aid, use of IV or heparin lock, gait status, and mental status.10, 11 Possible total scores range from 0 to 125, with higher scores denoting increased risk. At the study facility, the Morse Fall Scale assessment is performed every 12 hours, with scores greater than 45 indicating high risk of falling, scores between 25 and 45 indicating moderate risk, and scores less than 25 indicating low risk. The scale has been reported as having a sensitivity of 78%, positive predictive value of 10.3%, specificity of 83%, and negative predictive value of 99.2%; the interrater reliability score was 0.96.11 The tool is available online at www.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/morse-fall-scale.html.

Patients also completed the Patient Perception Questionnaire, a survey tool developed by Twibell and colleagues to measure patient perceptions about falls—specifically their confidence regarding the likelihood of falling, fear of falling, expectations about the outcomes of falls, and intention to engage in fall prevention activities.12 Permission to use this instrument for our study was obtained from the primary developer. The instrument includes three scales: the Confidence to Perform Without Falling Scale (hereafter, the Confidence scale), the Intention to Engage in Fall Prevention Scale (the Intention scale), and the Fear of Falling While Hospitalized Scale (the Fear scale), as well as three single questions. (We omitted a fourth scale, the Consequences of Falling While Hospitalized Scale.) The single questions measure a participant's “perceived likelihood of falling while hospitalized, perceived likelihood of injury if they did fall while hospitalized, and perceived fear of falling.”12

The Confidence and Intention scales are scored using a five-point Likert scale, with item responses ranging from 1 (strongly disagree) to 5 (strongly agree). The Fear scale is scored using a four-point Likert scale, with item responses ranging from 1 (not at all concerned) to 4 (very concerned). The three single questions are scored using a five-point Likert scale, with responses ranging from 1 (not at all likely) to 5 (very likely). All three scales have shown high internal consistency, with Cronbach α ranging from 0.90 to 0.95, as well as acceptable construct and criterion-related validity.12

Data analysis. Demographic data were analyzed using descriptive statistics. For continuous variables, means and standard deviations were calculated, and for categorical variables, frequencies and proportions were calculated. In keeping with the study's observational, cross-sectional design, summative scores on all measures related to fall risk perception were calculated. The Pearson correlation coefficient was used to estimate overall and service area relationships between confidence, intention, and fear of falling. Independent sample t tests were used to compare scale scores between groups of patients with a fall as the reason for admission, falls within the past three months, and falls within the past year. All analyses were completed using IBM SPSS software, version 25. Statistical significance was set at P ≤ 0.05.

RESULTS

The mean age of the sample was 65 years (range, 32 to 93 years); regarding gender, there were 52 male and 48 female patients. Nearly half of the 100 participants (49%) reported having fallen at least once in the three months prior to admission (mean number of falls, 1.48), and the majority (67%) reported having fallen in the past 12 months (mean number of falls, 2.75). More than a third (39%) had sustained an injury related to a fall; these ranged from scrapes and bruises to joint injuries and fractures of the arm, face, foot, leg, pelvis, or spine. Almost all (98%) participants reported being able to walk inside their homes before the current admission, with 49% of these using a cane or walker; 84% of all participants could transfer from bed to chair without assistance. A total of 85% were able to ambulate outside their homes, with 51% of these using a cane or walker. For more details on patient characteristics, see Table 1.

Table 1. - Patient Characteristics (N = 100) Characteristic Value Age in years, mean (SD)    Overall 65.3 (11.8)    Medicine 63.7 (13.3)    Neurology 66.6 (9.7)    Oncology 68.4 (9.7)    Surgery 62.6 (13.8) Gender, n (%)    Male 52 (52)    Female 48 (48) Race, n (%)    White 81 (81)    Black 19 (19) Length of stay in days, mean (SD) 7.7 (8) History of falling in past year, n (%) 67 (67)

Among all participants, the mean Morse Fall Scale score was 67.7 (range, 50 to 95), indicating that all were at high risk for falling. When asked in the Patient Perception Questionnaire if they considered themselves at risk for falls, only 55% reported that they did consider themselves at such risk. Perception of fall risk varied across hospital specialty units. The subgroup of patients from the oncology service reported the lowest perception of fall risk (48%) while patients from the neurology service reported the highest perception (60%). See Table 2 for more details.

Table 2. - Fall Risk Assessment Results Specialty Area Morse Fall Scale Score, mean (SD)a Patients Perceiving Self at Risk, %b Overall 67.7 (11.5) 55 Medicine 67.6 (12.3) 56 Neurology 67 (10.8) 60 Oncology 65.8 (11.6) 48 Surgery 70.4 (11.5) 56

aScore > 45 = high risk.

bBased on responses to the Patient Perception Questionnaire.

Regarding other responses to the Patient Perception Questionnaire, no significant differences between scores and specialty areas were found. For the Fear scale, the majority of participants (72%) reported being either not at all concerned or slightly concerned about falling while in the hospital; only 13% reported being very concerned. To the single item regarding perceived likelihood of injury if they were to fall while hospitalized, 72% reported they were not at all likely or slightly likely to be injured. For the Intention scale, 52% reported being very likely to ask for assistance to go to the bathroom, while 26% reported they were not likely to do so. For the Confidence scale, 50% of participants reported feeling confident they could go to the bathroom without help and without falling. See Table 3 for more details.

Table 3. - Patient Perception Questionnaire Results Scale Specialty Area Score, mean (SD) Confidence to Perform Without Fallinga

Medicine

Neurology

Oncology

Surgery

24.7 (8.7)

20 (10.1)

25.4 (10.2)

18.5 (8.3)

Intention to Engage in Fall Preventionb

Medicine

Neurology

Oncology

Surgery

28.7 (13.5)

34.3 (10.8)

29.8 (12.1)

35.7 (9.6)

Fear of Falling While Hospitalizedc

Medicine

Neurology

Oncology

Surgery

15.9 (9)

17.9 (9.7)

13.4 (7.2)

19.2 (8.2)

aItems scored 1-5; higher score = more confidence; maximum possible score = 35.

bItems scored 1-5; higher score = greater intention to engage; maximum possible score = 45.

cItems scored 1-4; higher score = greater fear; maximum possible score = 28.

Both overall and by specialty area, there were no significant correlations between the Morse Fall Scale score and either the Confidence scale score (r = −0.169) or the Intention scale score (r = 0.123). There was a small, but significant, positive correlation between the Morse Fall Scale score and the Fear scale score (r = 0.225).

Pearson r coefficient correlations between the Patient Perception Questionnaire scale scores are reported in Table 4. Negative correlations were noted between the Confidence and Intention scale scores and between the Confidence and Fear scale scores. This indicates that as a patient's confidence in their ability to perform mobility tasks without falling increased, their intention to ask for help and their fear of falling significantly decreased. A positive correlation was noted between the Intention and Fear scale scores, indicating that as a patient's fear of falling increased, their intention to ask for help also rose significantly.

Table 4. - Correlations Among Patient Perception Questionnaire Scale Scores (Pearson Correlation Coefficients)a Variable Intention Scale Fear Scale Confidence Scale Intention Scale 1 0.570 n = 99 −0.551 n = 99 Fear Scale 0.570 n = 99 1 −0.839 n = 100 Confidence Scale −0.551 n = 99 −0.839 n = 100 1

∗All correlations are significant at P < 0.001.

Note: Where n < 100, a response was missing.

There were some differences in Patient Perception Questionnaire scale scores based on whether a patient had or hadn't fallen within a given time frame, as reported in Table 5. Among participants who reported any history of falls within the past 12 months versus those who had not fallen, those who fell had lower Confidence and Intention scale scores and higher Fear scale scores, although the differences were not statistically significant. Among patients who had experienced a fall within the past three months versus those who had not, Intention and Fear scale scores were higher while Confidence scale scores were lower, although again the differences weren't significant. Lastly, among the participants who had been admitted due to a fall versus those hospitalized for other reasons, those who were admitted due to a fall had significantly lower Confidence and significantly higher Fear scale scores. They also had higher Intention scale scores, but the difference was not significant.

Table 5. - Comparison of Mean Scores for Patient-Reported Fall Categories Any Fall Past 12 Months Any Fall Past 3 Monthsa Admission Due to a Falla Scale No Fall (n = 33) Mean (SD) Fall (n = 67) Mean (SD) P No Fall (n = 50) Mean (SD) Fall (n = 48) Mean (SD) P No Fall (n = 86) Mean (SD) Fall (n = 13) Mean (SD) P Confidence scale 23.2 (8.6) 21.6 (10.2) 0.42 23.5 (9.3) 21.2 (9.9) 0.25 22.9 (9.7) 15.7 (6.9) 0.003b Intention scale 33.3 (11.5) 31.6 (12) 0.52 31.9 (12.2) 32.2 (11.6) 0.89 32 (11.9) 34.9 (9.2) 0.34 Fear scale 14.9 (7.8) 17.4 (9.1) 0.15 15 (8.1) 17.7 (9.1) 0.12 15.8 (8.7) 22.5 (6.7) 0.009b

aWhere total n < 100, one or more responses were missing.

bSignificant finding.

DISCUSSION

This study's findings demonstrate a disconnect between the results of clinical fall assessments and patients' perceptions of their fall risk. Based on their Morse Fall Scale scores, all the study participants were identified as being at high risk for falls, yet only 48% to 60% recognized this. Our findings regarding patients' inaccurate fall risk perceptions are in keeping with prior research findings. For example, in a study conducted among patients on acute care hospital units, Sonnad and colleagues found no correlation between the results of a formalized fall risk assessment and the patient's perception of fall risk; and despite being considered at risk for falls, most patients (88%) didn't feel they were at such risk.13 Similarly, Kuhlenschmidt and colleagues and Twibell and colleagues found that 33% and 55% of study participants, respectively, didn't feel they were at high risk for falls even though nursing assessments indicated otherwise.12, 14 And in a study exploring patient perspectives on hospital fall prevention education, Heng and colleagues found that many patients underestimated their risk of falling while hospitalized because they lacked adequate knowledge about fall prevention and also thought they were safer in the hospital than at home.15

When patients don't recognize they are at high risk for falls, their intention to engage in fall prevention activities may be adversely affected. In our study, the negative correlation between the Confidence and Intention scale scores indicated that as a patient's confidence in their ability to perform mobility tasks without falling increased, their intention to ask for help decreased despite being in the hospital. This negative correlation was also noted by Twibell and colleagues, who found that patients who reported high confidence in their ability to perform mobility tasks had low intention to engage in fall prevention activities.12 Radecki and colleagues found that among patients who were informed that they had a high fall risk, those without physical limitations didn't believe it.16 The researchers concluded that even when patients know they're at high risk for falls, they may still engage in risky behaviors if they perceive themselves to have good mobility.

In our study, a positive correlation between the Fear and Intention scale scores was found, indicating that participants who were more afraid of falling were more likely to adhere to fall prevention strategies. Moreover, participants who had been admitted as the result of a fall demonstrated lower Confidence and higher Fear scale scores than those admitted for non-fall-related reasons. Similarly, Kiyoshi-Teo and colleagues noted that patients who had fallen within the past three months or who had suffered a fall-related injury within the past 12 months were more likely to participate in fall prevention activities.17 This suggests that patients who have recently fallen, as well as those who have been injured in a fall, may have an increased fear of falling, which in turn might impact their engagement in fall prevention activities. In another study by Kiyoshi-Teo and colleagues, hospitalized patients who perceived their high fall risk to be temporary or modifiable were more likely to engage in fall prevention activities than those who perceived it to be permanent or unmodifiable.18

Tailoring education to each patient's perceptions of their fall risk may help patients become more aware of and better comprehend their fall risk while in the hospital. In our study, a history of falls was not significantly associated with the patient's perception of risk unless the reason for admission was due to a fall. It's essential to include the history of falls when assessing the risk of future falls, especially for patients hospitalized with an acute illness, and to discuss their current fall risk with both patients and families.

In the aforementioned study by Kuhlenschmidt and colleagues, patients in an acute care unit were formally assessed for fall risk by a nurse, surveyed about their perception of fall risk, and assigned to one of four fall risk categories that reflected both nursing assessment and patient survey results.14 The patients who received education tailored to their particular risk category became significantly more aware of their fall risk. Despite such increased awareness, though, the educational intervention had no effect on the patient's confidence regarding fall prevention or willingness to ask for assistance. In another study among patients in hospital rehabilitation units, Hill and colleagues reported significant reductions in fall and injurious fall rates after the implementation of an individualized fall prevention education program.19 In a recent scoping review by Heng and colleagues, the researchers found evidence that incorporating patient education into a hospital's fall prevention program helped to reduce falls.20 Noting that no single mode of education was effective for every patient in a given study, the researchers concluded that education should “take into account individual falls risks and environmental context.”

When providing education on fall prevention, health care providers should engage both the patient and family, discuss contributing factors that put this patient at risk for falls, and use a combination of educational modes (such as face-to-face discussion, handouts, and videos). Such individualized education may lead patients to a better understanding of their fall risk while in the hospital and could reduce fall rates.

Limitations. This study has several limitations. First, it involved a small convenience sample from a single large academic hospital, and it included only patients who were considered at high risk for falling based on their Morse Fall Scale scores. Thus, the results may not be generalizable to all patient populations. Second, it's possible that some participants' responses to the Patient Perception Questionnaire might not have been accurate. Lastly, we could not assess the accuracy of nurses' assessments of fall risk using the Morse Fall Scale, since those scores were obtained retrospectively.

Implications for practice and research. The results of this study support the findings of several other studies that examined the disconnect between a patient's perceived fall risk and their actual risk as based on their physiological status and the hospital environment.12-15 Clearly, appropriate fall prevention education and effective interventions are needed. Eliciting a patient's perception of their fall risk during an educational session might reveal that they don't recognize they are at risk even in the hospital. Providing individualized education that incorporates both the patient's perceived fall risk and the physiological and environmental fall risk factors may help the patient to better understand their actual risk. Such patient engagement is likely to lead to greater acceptance and practice of fall prevention activities, such as asking for help with mobility tasks.

Future research should focus on developing a fall risk screening instrument that incorporates the patient's perceived fall risk with the physiological and environmental fall risk factors that were present during hospitalization. Such an instrument could provide more accurate fall risk assessments. Once its reliability and validity are established, subsequent researchers could use the tool to evaluate interventions designed to engage patients and families in effective risk reduction and fall prevention strategies during acute care hospitalization.

CONCLUSIONS

This study's findings demonstrate the disconnect that often occurs in hospitalized patients between clinical fall risk assessment results and their own perception of that risk. Patients who don't recognize that they are at increased risk for falling, even when hospitalized, might not adhere to fall prevention strategies. Fall risk assessment should include not only a clinical evaluation of a patient's fall risk but also the patient's perception of their fall risk. Interventions that effectively address each patient's perception of risk as well as physiological and environmental risk factors could help reduce fall rates in the acute care setting.

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