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Doctor of Nursing Practice Papers School of Nursing

8-2019

Reducing Falls Through an Education Interventionto Increase Nurse-Promoted Mobility inHospitalized PatientsTamara SlaterUniversity of Louisville, tamaradslater@gmail.com

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Recommended CitationSlater, Tamara, "Reducing Falls Through an Education Intervention to Increase Nurse-Promoted Mobility in Hospitalized Patients"(2019). Doctor of Nursing Practice Papers. Paper 27.Retrieved from https://ir.library.louisville.edu/dnp/27

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Running head: REDUCING FALLS THROUGH AN EDUCATION INTERVENTION

REDUCING FALLS THROUGH AN EDUCATION INTERVENTION TO

INCREASE NURSE-PROMOTED MOBILITY IN HOSPITALIZED PATIENTS

by

Tamara Slater

Paper submitted in partial fulfillment of the

requirements for the degree of

Doctor of Nursing Practice

University of Louisville

School of Nursing

August 7,2019

Signature DNP Project Committee Member

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Signature Program Director

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Signature Associate Dean for Academic Affairs Date

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REDUCING FALLS THROUGH AN EDUCATION INTERVENTION 2

Acknowledgments

I would like to thank my husband Nathaniel, and my mother Denise, for their love, support, and

for always being my biggest cheerleaders. I would also like to thank my project chair, Beverly

Williams-Coleman and committee member, Celeste Shawler, for their knowledge and expertise

that have guided me through this process.

REDUCING FALLS THROUGH AN EDUCATION INTERVENTION 3

Dedication

I would like to dedicate this work to the registered nurses working tirelessly to keep

patients safe.

REDUCING FALLS THROUGH AN EDUCATIONAL INTERVENTION 4

Table of Contents

Manuscript Title Page ............................................................................................................1

Acknowledgments..................................................................................................................2

Dedication ..............................................................................................................................3

Manuscript Abstract ...............................................................................................................5

Manuscript…………………………………………………………………………………..6

References ..............................................................................................................................19

Appendix A: Mobility algorithm ...........................................................................................22

Appendix B: Flyer.................................................................................................................23

Appendix C: Mobility Knowledge Questionnaire ................................................................24

Appendix D : Approval letter ...............................................................................................26

REDUCING FALLS THROUGH AN EDUCATION INTERVENTION 5

Abstract

The aim of this project was to determine if educating registered nurses (RNs) on the

importance of nurse-promoted patient mobilization could increase RN knowledge on patient

mobility and reduce the rate of patient falls on a cardiology/neurology nursing unit in a

southeastern area of the United States. This project was a quality improvement project with a

pre-test/post-test design. The intervention included a teaching session for RNs and posted

reminders. The teaching session included information on the use of a mobility algorithm, where

to locate mobility equipment, and the physical therapy referral process. The reminders included

flyers posted around the unit with abbreviated content covered in the teaching sessions. The

Mobility Knowledge Questionnaire was used to assess the educational topics covered in the

mobility teaching session. Accuracy scores out of eight were collected prior to the teaching

session and four weeks following the teaching session. Mobility Knowledge Questionnaire

accuracy scores improved significantly (p=.021) four weeks after the intervention. Fall rates did

not improve, but rather, worsened (4.3 falls per 1,000 bed days pre- and 9.6 falls per 1,000 bed

days post-intervention.) Recommendations for future quality improvement initiatives at this

facility include making the mobility algorithm more accessible to RNs in addition to providing

education in a format similar to what has been used in this project to determine if this tool is

useful in increasing nurse-promoted mobility on this unit and impacting falls.

Key words: mobility; falls; inpatients; hospitalization; hospital inpatients; exercise; walks with

nursing; nurse-promoted mobility; evidence-based; quality improvement; DNP project

REDUCING FALLS THROUGH AN EDUCATIONAL INTERVENTION 6

Reducing Falls through an Education Intervention to Increase Nurse-promoted Mobility in

Hospitalized Patients

The World Health Organization (WHO) (2018) defines a fall as “an event which results

in a person coming to rest inadvertently on the ground, floor, or other lower level.” Falls are a

long-standing problem faced by care centers and older people and account for the majority of

nonfatal and fatal injuries which contribute to decreased quality of life (De Guzman,

Lacampuenga, & Lagunsad 2015). According to the Agency for Healthcare Research and

Quality (AHRQ) (2018), between 700,000 and 1,000,000 people in the United States fall in the

hospital each year. Inpatient falls are costly; the average cost for a fall injury in the hospital is

over $30,000 (Burns, Stevens, & Lee, 2016). A fall experienced by an older person can have

significant long- and short-term consequences such as pain, discomfort, injury, reduced mobility,

and increased healthcare use (AHRQ, 2018; Barker, 2014). Several factors contribute to inpatient

falls: weakness due to medical status or prolonged immobilization; medications such as

benzodiazepines, narcotics, diuretics, and laxatives; patient mental status changes or confusion;

unfamiliar environment; and trip hazards such as medical equipment cords and intravenous

medication tubing (Healey & Darowski, 2012).

In 2017, a nursing unit at a suburban hospital in southeastern United States had 71 patient

falls which accounted for 15% of all patient falls in the hospital. There were several fall

prevention strategies in place which included bed alarms and chair alarms in every room, hourly

rounding on all patients, nonskid socks, an “arms reach” protocol for high-risk patients, and fall

risk assessment screening of all patients on every 12-hour shift. While these strategies have

shown some improvement in the fall rate over time (there were 66 falls in 2018), the fall rate on

this unit is still considered to be a problem by nursing leadership and administration.

REDUCING FALLS THROUGH AN EDUCATION INTERVENTION 7

Hospitalized patients who do not sufficiently mobilize are more likely to sustain negative

health outcomes than those who do sufficiently mobilize (Demody & Kovach, 2018). The

deconditioning and decline from a patient’s baseline functioning can occur as early as day 2 of

hospitalization in elderly patients (Kleinpell, Fletcher, & Jennings, 2008). Muscle strength can

decrease up to 10% after each week of bedrest (Mustian et al., 2009). Loss of strength in addition

to decreased muscle mass, decreased plasma volume, and reduced cardiac output found as a

result in bedrest has been linked to increased falls and in length of stay (Crannell & Stone, 2008;

Mustian et al., 2009). If the patient is able to perform some physical activity during their

hospitalization, this delays the muscle loss which contributes to weakness and falls (Crannell &

Stone, 2008; Mustian et al., 2009).

Barriers to adequate patient mobility involve patient attitude and registered nurse (RN)

knowledge. According to a descriptive study by Dermody & Kovach (2017), patients may have a

passive attitude about mobility due to a multitude of factors; they may feel ill, lack education on

mobility benefits, require assistance to get out of bed, or feel burdensome to ask for help. On the

other hand, some barriers lie with RN attitude as well. RNs may think that they lack the

knowledge and training to safely mobilize their patients (Dermody & Kovach, 2018). Despite

these barriers, educating RNs has been used in the literature as an effective strategy in reducing

fall rates in other fall prevention programs (Krauss et al., 2008; Liu, Shen & Xiao, 2012).

This hospital currently does not have a nursing protocol or prevailing nursing practice for

ambulating patients. There is a mobility algorithm (Appendix B) approved and suggested for use

as a guide for clinical decision making regarding patient ambulation, however it is underutilized.

The algorithm addresses such issues as patient weight bearing status, cooperation, muscle

strength, and safety risk status (United States Department of Veterans Affairs, n.d.).

REDUCING FALLS THROUGH AN EDUCATION INTERVENTION 8

Theoretical Framework

Adult Learning Theory by Knowles, Holton, & Swanson (2005), was used to guide this

project development. The constructs used are the six assumptions of adult learners. The first

construct is that adult learners 1) “Need to know”--adults need evidence for an intervention in

order to learn it. 2) Adult learners need self-direction in their learning. This construct was

addressed by allowing participants to have input in the content and process in their learning. That

is to say, teaching content was open to discussion. Participants were given the opportunity to

share their experiences and give feedback on the presented content. 3) Adult learners need to

share their experiences in order to maximize learning. Focus was placed on adding to what they

already know instead of presenting new information. 4) Adults’ readiness to learn is affected by

real-life problems and situations. Since the high number of inpatient falls is a real-life problem

that affects these nurses, this assumption is easily met. The focus should be on solving the real-

life problem rather than memorizing the presented content. 5) The orientation assumption refers

to the internal and external motivators that drive participants of various backgrounds and

maturity levels. As adults mature, they are more motivated by internal motivators rather than

external motivators. For example, a new nurse may be more motivated by doing what an

authority figure wants her to do and a mature nurse may be more motivated by a desire to do

what she feels like is best for the patient. 6) The last assumption of the adult learner is that of

motivation. Adult learners are mostly motivated to learn information that can be applied

immediately.

Setting and Organizational Assessment

The setting is a 42-bed cardiology/neurology step-down nursing unit at a suburban

hospital in a southeastern area of the United States. Stakeholders include: patients on this nursing

REDUCING FALLS THROUGH AN EDUCATION INTERVENTION 9

unit, RNs on this unit, nursing management, administration, and the hospital’s nursing quality

council. Permission to complete this project was obtained from the facility’s quality council

director and university IRB (Appendix D).

Purpose

The aim of this quality improvement project is to determine if educating RNs on the

importance of nurse-promoted patient mobilization could increase RN knowledge on the topic of

patient mobility and reduce the rate of patient falls on a cardiology/neurology unit.

Intervention

The intervention included a teaching session for RNs. A PowerPoint presentation was

used and the content was delivered in seminar format which allowed for discussion by the

participants during the session and questions answered after the session. The teaching session

provided evidence for the benefits of patient mobilization in order to gain buy-in. Information on

clinical decision making through the use of a mobility algorithm (Appendix A) was included in

the teaching session, as barriers to patient mobilization can include RN confidence in their ability

to safely mobilize their patients.

The mobility algorithm (Appendix A) approved for use at this facility was found to be

underutilized by the RNs. In fact, only one out of thirteen participants reported that they knew

how to access the mobility algorithm on the Mobility Knowledge Questionnaire pre-test. The

algorithm is a tool designed to help RNs make appropriate decisions concerning patient mobility.

The algorithm addresses weight-bearing status, patient cooperation, upper body strength,

grasping ability, etc. and gives recommendations for how the patient should be transferred. The

teaching session included information on how to access and use the mobility algorithm, where to

locate mobilization equipment, and the referral process for inpatient physical therapy.

REDUCING FALLS THROUGH AN EDUCATION INTERVENTION 10

Participants

The target population was RNs working on a cardiology/neurology step-down unit at a

suburban hospital in a southeastern area of the United States. Criteria for inclusion as a

participant was to be a RN working full-time or part-time on the target unit. Exclusion criteria

included “float” RNs who did not work primarily on the target unit and RNs who work per diem

or on a leave of absence during the intervention period as it would have been difficult to deliver

the intervention to these groups as they may not be easily accessible due to minimal work hours.

Recruitment was done via email sent by the unit manager and the DNP student, a flyer posted in

the employee breakroom and in the employee restroom, and by word-of-mouth.

Completion of the pre-test served as the pre-amble for consent. The pre-test was

administered by the DNP student and any questions regarding the project, data collection, data

usage, participant anonymity, etc. were answered at that time. Participants were informed that

they could refuse participation at any point in the project.

The sample included 13 female RN’s that worked full-time with 1-5 years of experience

on the nursing unit (12 out of 13 participants). One RN had 6-10 years of experience on the unit.

The participants’ ages ranged from 25-55 years, with four nurses aged 25-35, six aged 36-45, and

three aged 46-55. Eleven out of thirteen nurses had a Bachelor’s degree, one had an Associate’s

degree, and one had a Master’s degree. The participants had a wide-range of nursing experience

including critical care, emergency room, nursing home, administration, and other areas. Nine

participants out of thirteen completed both the pre-test and the post-test. One participant changed

jobs in the four-week period following the pre-test administration and three participants did not

respond to the email containing the instructions for completing the post-test.

REDUCING FALLS THROUGH AN EDUCATION INTERVENTION 11

Data Collection

All the data was collected by the DNP student and included demographic data, responses

to the Mobility Knowledge Questionnaire, and fall rates on the nursing unit. Data was stored on

an encrypted and password-protected computer. Confidentiality and anonymity of participants

was maintained. Demographic data was collected immediately prior to the teaching session

during the April 2019 Unit-based shared governance (UBSG)/staff meeting. Mobility

Knowledge Questionnaire accuracy scores were also collected at this time. Four weeks following

the teaching intervention, the Mobility Knowledge Questionnaire was administered again to the

participants who completed the pre-test. The second administration was conducted via the

facility’s secure email system.

The project proposal was approved by the University Institutional Review Board (IRB) as

a quality improvement protocol (exempt status). This was done to ensure that research be

conducted in accordance with federal and state regulations and university and sponsoring agency

policies and procedures instituted to protect the rights and welfare of participants.

Participants were educated on the referral process for inpatient physical therapy (PT).

This was done to ensure that patients who need extra help mobilizing, beyond with the RN can

provide would be appropriately referred. Referrals were to be made to the facility’s PT

department as deemed appropriate by the patient’s provider.

The teaching session occurred during voluntary UBSG and staff meeting and did not

require any additional working time from the RNs. Teaching materials including a projected

PowerPoint presentation with printed copies of PowerPoint slides and flyers (Appendix B)

posted around the unit were financed by the DNP student.

REDUCING FALLS THROUGH AN EDUCATION INTERVENTION 12

Measurement

Measured data included demographic data which was used to describe the sample. This

data was gathered at the same time as the pre-test and was included on the same form. This data

included: age, gender, full-time/part-time status, years of RN experience, years of experience on

current unit, previous type of RN experience, and education level attained.

RN knowledge was measured via pre- and post-test of the Mobility Knowledge

Questionnaire (Appendix C). The questionnaire includes eight questions which assess the three

educational topics covered in the mobility teaching session: 1) Accessing and using the mobility

algorithm, 2) The location of mobility equipment, and 3) PT referral process. Accuracy scores

out of eight were collected prior to the teaching session and four weeks following the teaching

session.

Fall rates were measured for the four-week period prior to the start of the intervention and

four weeks following the intervention. Fall rates are reported as the number of falls per 1,000

occupied bed days. To calculate, divide the number of falls by the number of occupied bed days

for the six week period, then multiply the result by 1,000. The fall data is routinely collected by

the quality director who provided this information.

Results

The Mobility Knowledge Questionnaire responses and participant demographic data were

analyzed using IBM’s SPSS statistical software. The Mobility Knowledge Questionnaire

accuracy scores out of eight were compared using a paired t-test. The mean score out of 8 for the

pre-test was 6.22 (77.8% accuracy) and for the post test was 7.11 (88.9% accuracy) with a

REDUCING FALLS THROUGH AN EDUCATION INTERVENTION 13

statistically significant p-value of 0.021when comparing the pre- and post-intervention scores

with p<0.05 being the threshold for significance.

Table 1: Mobility Knowledge Questionnaire Scores (out of eight) Paired T-test Results

The fall rate for the 4-week period prior to the intervention was 4.3 falls per 1,000 patient

days. The fall rate period for the 4-week period after the intervention was 9.6 falls per 1,000

patient days. Therefore, the fall rate doubled in in the four-week period after the intervention. As

a reference point, this unit averaged about 5.5 falls per month in 2018. According to the Agency

for Healthcare Research and Quality (AHRQ) falls occur anywhere from 1.7 to 25 falls per 1,000

patient days, depending on the type of unit, with geriatric psychiatry patients having the highest

risk (Ganz, Huang, Saliba, & Shier, 2013). According to a 2014 study, US hospital falls ranged

from 3.3 to 11.5 falls per 1,000 patient days. This study found that the highest rates of falls

REDUCING FALLS THROUGH AN EDUCATION INTERVENTION 14

occurred on neurosurgery, neurology, and medicine units and the lowest occurred on surgical

and intensive care units (Bouldin, Andresen, Dunton, Simon, Waters, Liu, et al., 2013).

Discussion

Interpretation

The teaching session format that was used to educate RNs was useful in conveying

information, and it is clear that some information was retained as evidenced by the increase in

Mobility Knowledge Questionnaire scores, however, this information may need to be repeated

for it to be committed to memory. After receiving the education, only five RNs out of the nine

that completed the post-test, got question number one correct “How do you access the mobility

algorithm?” With so few RNs remembering how to access the tool, it is doubtful that they used it

in the four-weeks after the intervention.

The over-double increase of the fall rate in the four week period after the intervention is

undoubtedly multi-factorial, and since this project only impacted thirteen out of thirty-four RNs

(38%) who typically work on the unit, and did not include nursing assistants, prn RNs, or float

RNs, it is unlikely that there is a causal relationship. However, during this four-week period, the

unit had a change in nursing management, and lost 2 RNs and 3 nursing assistants (J. Detinger,

personal communication, July 11, 2019). A more in-depth analysis is necessary to come to

conclusions about what other factors may or may-not have contributed to the higher rate of falls

during this period. It is possible that other factors such as higher than usual patient acuity, or

patient diagnoses may have also contributed.

The intervention was easy to administer, however, getting RNs to attend a voluntary

meeting proved to be difficult. Recommendations for future quality improvement initiatives may

include making the mobility algorithm more accessible to RNs in addition to providing education

REDUCING FALLS THROUGH AN EDUCATION INTERVENTION 15

in a format similar to what has been used in this project to truly determine if this tool is useful in

increasing nurse-promoted mobility on this unit and impacting falls.

Limitations

The limitations to this project included poor attendance to the teaching session. Thirteen

out of 34 RNs working full-time or part-time on the unit attended the UBSG/staff meetings.

These meetings were not mandatory, but highly encouraged as they are intended to pass on

important information and discuss topics related to nursing on the unit. A second session was

offered later in the day but no RNs attended. Another limitation is that some RNs do not check or

respond to their work email. The post-test was administered using this platform and only nine out

of thirteen responded, however, one RN left her position at the hospital.

Although difficult to assess, one possible limitation is participant reception to the topic.

During the four-week period following the intervention, no RNs reached out with questions,

comments, or concerns regarding the teaching material, which calls to questions if the RNs found

this information valuable, interesting, or a high priority.

Conclusion

Inpatient falls is a local, national, and global problem. The literature supports educating

nurses about patient mobility as one of many strategies to prevent falls. This quality

improvement project attempted to determine if educating RNs on nurse-promoted patient

mobility could be helpful in reducing the fall rates on a cardiology/neurology unit. The Mobility

Knowledge Questionnaire was administered pre- and post-intervention and showed a statistically

significant (p=0.021) increase in RN knowledge following the teaching session. However, it was

found on the post-test that only five out of nine RNs could recall how to access the mobility

algorithm, which calls to question if it was used by these RNs following the teaching, and if it

REDUCING FALLS THROUGH AN EDUCATION INTERVENTION 16

would be unlikely that they would use it in the future. If the facility’s nursing administration

continues to feel strongly that this tool could be useful to their RNs while caring for patients,

they may consider making the tool more accessible in addition to providing education for RNs

similar to what was used for this project.

Fall rates did not decrease, but rather increased following the teaching sessions. It is

unlikely that this high fall rate was a result of the intervention due to the small number of

participants, as well as the multifactorial nature of inpatient falls. However, data would need to

be collected for a longer period of time and with more participants to establish what kind of

correlation exists between this intervention and fall rates. Recommendations for future quality

initiatives at this facility include providing this education on a larger scale to capture more

participants, looking at fall rates for a longer period of time to determine if a correlation exists

between this intervention and fall rates, and choosing a tool that is more accessible to RNs so

that they would be more likely to use it, preferably one that fits within their current workflow.

Inpatient falls is a broad topic that has been studied for years. Due to the complexity of

various patient populations, diagnoses, level of patient impairment, staffing ratios, and many

other factors, future quality improvement projects in this area could go in a multitude of

directions. The nursing unit targeted in this project has an ongoing staffing shortage and this may

be one area that could be addressed in future quality improvement initiatives.

Recent hospital fall prevention strategies that have been reported in the literature include

multifactorial interventions and singular interventions such as exercise/physical therapy,

staff/organizational changes, knowledge-based interventions, bed exit alarms, identification

bracelets for high risk fallers, and medication interventions (Cameron, et al., 2018). The six

multifactorial interventions that were studied in the Cochran systematic review by Cameron, et

REDUCING FALLS THROUGH AN EDUCATION INTERVENTION 17

al. (2018) did not show strong evidence for a decline in fall rate or risk of falling. Knowledge-

based interventions showed strong evidence for a reduction in the rate of falls in participants who

are cognitively intact, but not those who are not cognitively intact (Haines, 2011).

Exercise/physical therapy interventions did not provide evidence for a reduction in rate of falls,

but two trials (83 participants) showed a reduction in the risk of falling. The other interventions

mentioned in the Cameron, et al. (2018) review either did not give sufficient evidence that they

effect fall rates or risk of falling, or the studies were too poor in quality to make a determination.

Further research is warranted into supervised exercise programs, particularly for

larger trials that clearly describe the care needs of the involved patients. Further research

is also warranted to strengthen the evidence for multifactorial interventions with emphasis

on a creating individualized, standardized approaches to the delivery of interventions.

Further trials testing the routine use of validated falls risk assessment tools; interventions

that target staff/organizational system; trials of additional exercise, social environment and

knowledge interventions; and further research focusing on participants with cognitive

impairment also are needed (Cameron, et al., 2018).

REDUCING FALLS THROUGH AN EDUCATION INTERVENTION 18

References

Agency for Healthcare Research and Quality (AHRQ). (2018). Falls prevention. Retrieved

October 25, 2018 from: https://www.ahrq.gov/topics/falls-prevention.html

Barker, W. (2014). Assessment and prevention of falls in older people. Nursing Older

People, 26(6), 18-24. doi:10.7748/nop.26.6.18.e586

Booth, K., Rivet, J., Flici, R., Harvey, E., Hamill, M., Hundley, D., & ... Collier, B. (2016).

Progressive mobility protocol reduces venous thromboembolism rate in trauma

intensive care patients: A quality improvement project. Journal of Trauma

Nursing, 23(5), 284-289. doi:10.1097/JTN.0000000000000234

Bouldin, E.D., Andresen, E.M., Dunton, N.E., Simon, M., Waters, T.M., Liu, M, et al. (2013).

Falls among adult patients hospitalized in the United States: Prevalence and Trends.

Journal of Patient Safety, 9(1):13-17. doi:10.1097/PTS.0b013e3183699b64

Burns, E.B., Stevens, J.A., Lee, R.L. (2016). The direct costs of fatal and non-fatal falls among

older adults—United States. Journal of Safety Research, 58, 99-103.

https://doi.org/10.1016/j.jsr.2016.05.001

Cameron, I.D., Dyer, S.M. Panagoda, C.E., Murray, G.R., Hill, K.D., Cumming, R.G., Kerse, N.,

(2018). Interventions for preventing falls in older people in care facilities and hospitals

(Review). Cochrane Database of Systematic Reviews 2018, 9,

doi:10.1002/14651858.CD005465.pub4.

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 2012, 12.

doi:10.1002/14651858.CD005465.pub3.

REDUCING FALLS THROUGH AN EDUCATION INTERVENTION 19

Crannell, C.E., & Stone, E. (2008). Bedside physical therapy project to prevent deconditioning in

hospitalized patients with cancer. Oncology Nursing Forum, 35, 343–345. doi:10.1188/08

.ONF.343-345

Czaplijski, T., Marshburn, D., Hobbs, T., Bankard, S., & Bennett, W. (2014). Creating a culture

of mobility: An Interdisciplinary approach for hospitalized patients. Hospital Topics, 92,

74-79. DOI: 10.1080/00185868.2014.937971

Dermody, G., & Kovach, C. (2018). Barriers to promoting mobility in hospitalized older adults.

Research In Gerontological Nursing, 11, 17- 27

Dermody, G. & Kovach, C. (2017) Nurses’ experience with and perception of barriers to

promoting mobility in hospitalized older adults: A descriptive study. Journal of

Gerontological Nursing, 43, 22-29

De Guzman, A. B., Lacampuenga, P. U., & Lagunsad, A. V. (2015). Examining the structural

relationship of physical activity, cognition, fear of falling, and mobility limitation of

Filipinos in Nursing Homes. Educational Gerontology, 41(7), 527-542.

doi:10.1080/03601277.2014.986398

Ganz, D.A, Huang, C., Saliba, D., Shier, V. (2013). Preventing falls in hospital: A toolkit for

improving quality of care. Agency for Healthcare Research and Quality; January 2013.

Gillespie L., Robertson, M., Gillespie, W., Sherrington, C., Gates, S., Clemson, L., Lamb,

S.(2012). Interventions for preventing falls in older people living in the

community. Cochrane Database of Systematic Reviews, 9.

doi:10.1002/14651858.CD007146.pub3.

REDUCING FALLS THROUGH AN EDUCATION INTERVENTION 20

Haines, T.P., Hill, A.M., Hill, K.D., McPhail, S., Oliver, D., Brauer, S., et al. (2011). Patient

education to prevent falls among older hospital inpatients: a randomized controlled trial.

Archives of Internal Medicine, 171(6); 516-24

Healey, F. & Darowski, A. (2012). Older patients and falls in hospital. Clinical Risk, 18, 170-

176. doi: 10.1258/cr.2012.012020

Kleinpell, R.M., Fletcher, K., & Jennings, B.M. (2008). Reducing functional decline in

hospitalized elderly. In: Hughes, R.G. (Eds.). Patient Safety and Quality: An Evidence-

Based Handbook for Nurses (Ch. 11). Rockville: Agency for Healthcare Research and

Quality (US). Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK2629/

Krauss, M., Tutlam, N., Costantinou, E., Johnson, S., Jackson, & D., Fraser, V. (2008).

Intervention to prevent falls on the medical service in a teaching hospital. Infection

Control and Hospital Epidemiology, 29, 539-545

Knowles M., Holton, E., & Swanson, R. (2005) The Adult Learner: The Definitive Classic in

Adult Education and Human Resource Development. 6th edition. Amsterdam: Elsevier.

Lee, S. H., & Kim, H. S. (2017). Exercise interventions for preventing falls among older people

in care facilities: A Meta-Analysis. Worldviews On Evidence-Based Nursing, 14(1), 74-

80. doi:10.1111/wvn.12193

Liu, H., Shen, J., & Xiao, L. (2012). Effectiveness of an educational intervention on improving

knowledge level of Chinese registered nurses on prevention of falls in hospitalized older

people—A randomized controlled trial. Nurse Education Today, 32,695-702.

doi:10.1016/j.nedt.2011.09.009

REDUCING FALLS THROUGH AN EDUCATION INTERVENTION 21

McLaughlin, T. M., Wittstein, E. R., White, T. H., Czaplinski, C. A., & Gerard, S. O. (2012).

Moving to Wellness: A Pilot Study Examining a Nurse-Driven Exercise Program in

Acutely Ill Patients With Cancer. Clinical Journal Of Oncology Nursing, 16(3), E105-10.

Mustian, K.M., Peppone, L., Darling, T.V., Palesh, O., Heckler, C.E., & Morrow, G.R. (2009). A

4-week home-based aerobic and resistance exercise program during radiation therapy: A

pilot randomized clinical trial. Journal of Supportive Oncology, 7(5), 158–167.

Pashikanti, L., Von Ah, D. (2012). Impact of early mobilization protocol on the medical-surgical

inpatient population. Clinical Nurse Specialist, 87—94.

doi:10.1097/NUR.0b013e31824590e6

Polit, D.F. & Beck, C.T. (2014). Essentials of nursing research: Appraising evidence for nursing

Practice (8th ed., pp. 22-24). Lippincott Williams & Wilkins; Philadelphia, PA.

United States Department of Veterans Affairs (n.d.). Mobility algorithm. Retrieved from:

http://www.visn8va.gov/VISN8/PatientSafetyCenter/safePtHandling/SPHGuidebook.doc

Wood, W., Tschannen, D., Trotsky, A., Grunawalt, J., Adams, D., Chang, R., Kendziora, S., &

Diccion-MacDonald, D. (2014). A mobility program for an inpatient acute care medical

unit. The American Journal of Nursing, 114(10),34-40

World Health Organization. (2018). Falls. Retrieved from: http://www.who.int/news-room/fact-

sheets/detail/falls

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Appendix A: Mobility Algorithm

(U.S. Department of Veterans Affairs, n.d.)

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Appendix B: Flyer

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Appendix C: Mobility Knowledge Questionnaire

Correct answers have been highlighted with reference to answer on PowerPoint (not included on

participants’ copy).

Please choose only one correct answer and fill it in the ( ).

1. How do you access the mobility algorithm? ( )

A. Print it from optio.

B. View it in EPIC.

C. View it in Outlook email.

2. Are walkers available for patient use? ( )

A. No, patients must provide their own walker

B. Only when PT/OT brings them.

C. Yes, and they are located in the med room on 5 North and the stock room on 5 South.

3. True or False: I always need to wait for Physical Therapy to evaluate my patients prior to

getting them out of bed. ( )

A. True

B. False

4. True or False: An RN can order physical therapy for a patient per protocol without a

cosign. ( )

A. True

B. False

5. Which of the following is true of patient mobilization in the hospital? ( )

A. It decreases patient deconditioning and functional decline which contributes to falls.

B. It increases the risk of patient falls since patients are moving around more.

C. It increases the risk of patient elopement for confused patients.

6. Use the mobility algorithm (attached) to answer the following question: Mr. J is a 68 year

old patient who was admitted to the hospital with pneumonia. Prior to being admitted, he

lived at home and was walking independently. His pneumonia has made him feel a little

weak and he requires 2L of O2 to keep his oxygen saturation level above 92%. You

assess Mr. J and find that he is able to fully bear weight on his lower extremities. Would

you allow Mr. J to transfer and how?

A. No, because he requires oxygen to keep his oxygen saturation level up.

B. No, because he is weaker than when he came into the hospital.

C. Yes. He can transfer with the assistance of 1-2 caregivers and a portable oxygen tank.

D. Yes. He can remove his oxygen and walk around the nurses station by himself.

7. Use the “Progressive Upward Mobility Program Activity Levels” portion of the mobility

algorithm (attached) to answer the following question: Mrs. L is a 74 year old patient

who was admitted to your unit yesterday evening as a transfer from ICU with the

diagnosis of gastrointestinal bleeding. She is no longer actively bleeding and her

hemoglobin this morning was 12. She feels very week after being bedbound in ICU for 4

days. The most she has done is sit up in the bed for meals. She said before she was

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admitted to the hospital she could move around her house pretty well with a rolling

walker. You know that it is important for Mrs. L to start moving around to prevent further

deconditioning and functional decline. What do you decide to try? ( )

A. Consult physical therapy and wait for them to evaluate the patient prior to doing

anything.

B. Ask the admitting physician if she would like to order physical therapy for the

patient. Help her dangle on the side-of-bed and see how she does. If she tolerates

eating her breakfast sitting on the side of the bed, help her up to the recliner for lunch

and dinner.

C. The patient does not need a physical therapy consult. Help them walk around the

nurses station with a gait belt and walker.

8. Use the mobility algorithm (attached) to answer the following question: Mrs. M is a 52

year old patient with severe multiple sclerosis who lives in a long-term care facility and

requires a ceiling lift with sling and 2 care providers to get up in the chair. She was

admitted to our unit with the diagnosis of CVA which has cause right arm and leg

weakness and numbness. Her brother comes to visit her in the hospital and asks you if

she can get up. What do you say? ( )

A. “Of course, let me go grab a gait belt and some non-skid socks!”

B. Yes, let me go grab the mechanical lift and I will get her up in the chair.

C. I would like to see if Physical Therapy has seen her yet and what they recommend. I

want to make sure that she is safe to sit up in the chair after this new stroke.

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Appendix D: Approval Letter