Journal of Gerontological Nursing

CNE Article 

Do Sitters Prevent Falls?: A Review of the Literature

Carrie E. Lang, RN, MSN, CNL

Abstract

How to Obtain Contact Hours by Reading This Article
Instructions

1.2 contact hours will be awarded by Villanova University College of Nursing upon successful completion of this activity. A contact hour is a unit of measurement that denotes 60 minutes of an organized learning activity. This is a learner-based activity. Villanova University College of Nursing does not require submission of your answers to the quiz. A contact hour certificate will be awarded once you register, pay the registration fee, and complete the evaluation form online at https://villanova.gosignmeup.com/dev_students.asp?action=browse&main=Nursing+Journals&misc=564. To obtain contact hours you must:

Read the article, “Do Sitters Prevent Falls? A Review of the Literature” found on pages 24–33, carefully noting any tables and other illustrative materials that are included to enhance your knowledge and understanding of the content. Be sure to keep track of the amount of time (number of minutes) you spend reading the article and completing the quiz.

Read and answer each question on the quiz. After completing all of the questions, compare your answers to those provided within this issue. If you have incorrect answers, return to the article for further study.

Go to the Villanova website listed above to register for contact hour credit. You will be asked to provide your name; contact information; and a VISA, MasterCard, or Discover card number for payment of the $20.00 fee. Once you complete the online evaluation, a certificate will be automatically generated.

This activity is valid for continuing education credit until April 30, 2016.

Contact Hours

This activity is co-provided by Villanova University College of Nursing and SLACK Incorporated.

Villanova University College of Nursing is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

Activity Objectives

Describe the correlation between sitter use and fall prevention.

Review ways that sitters can affect the workflow of nursing care with patient and family satisfaction.

Disclosure Statement

Neither the planners nor the author have any conflicts of interest to disclose.

Preventing falls is a primary nursing concern, especially among older adult patients. Employing a sitter is a common but costly intervention. This article is a comprehensive review of the literature on sitter use and its effect on fall rates in acute care. The search was conducted in CINAHL, MEDLINE, PsycINFO, and the Psychology and Behavioral Sciences Collection and included articles published between 1995 and 2013. The articles included reported data on studies increasing or decreasing sitter use. Sitter reduction studies showed no increase in fall rates; studies implementing sitters to reduce falls showed conflicting results. Implications include the impact to staffing and nursing practice that results from sitter use, the need for staff education programs, how sitter use can affect patient satisfaction, and the need for additional, more robust research on this topic to determine whether sitter use is evidence-based practice. [Journal of Gerontological Nursing, 40 (5), 24–33.]

Ms. Lang is Medical-Surgical Nurse, Neuroscience/Renal Transplant/ Nephrology Unit, Virginia Mason, Seattle, Washington.

The author has disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Carrie E. Lang, RN, MSN, CNL, 5438 125th Avenue SE, Bellevue, WA 98006; e-mail: Carrie.Lang@gmail.com.

Received: July 19, 2013
Accepted: February 25, 2014
Posted Online: March 19, 2014

Abstract

How to Obtain Contact Hours by Reading This Article
Instructions

1.2 contact hours will be awarded by Villanova University College of Nursing upon successful completion of this activity. A contact hour is a unit of measurement that denotes 60 minutes of an organized learning activity. This is a learner-based activity. Villanova University College of Nursing does not require submission of your answers to the quiz. A contact hour certificate will be awarded once you register, pay the registration fee, and complete the evaluation form online at https://villanova.gosignmeup.com/dev_students.asp?action=browse&main=Nursing+Journals&misc=564. To obtain contact hours you must:

Read the article, “Do Sitters Prevent Falls? A Review of the Literature” found on pages 24–33, carefully noting any tables and other illustrative materials that are included to enhance your knowledge and understanding of the content. Be sure to keep track of the amount of time (number of minutes) you spend reading the article and completing the quiz.

Read and answer each question on the quiz. After completing all of the questions, compare your answers to those provided within this issue. If you have incorrect answers, return to the article for further study.

Go to the Villanova website listed above to register for contact hour credit. You will be asked to provide your name; contact information; and a VISA, MasterCard, or Discover card number for payment of the $20.00 fee. Once you complete the online evaluation, a certificate will be automatically generated.

This activity is valid for continuing education credit until April 30, 2016.

Contact Hours

This activity is co-provided by Villanova University College of Nursing and SLACK Incorporated.

Villanova University College of Nursing is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

Activity Objectives

Describe the correlation between sitter use and fall prevention.

Review ways that sitters can affect the workflow of nursing care with patient and family satisfaction.

Disclosure Statement

Neither the planners nor the author have any conflicts of interest to disclose.

Preventing falls is a primary nursing concern, especially among older adult patients. Employing a sitter is a common but costly intervention. This article is a comprehensive review of the literature on sitter use and its effect on fall rates in acute care. The search was conducted in CINAHL, MEDLINE, PsycINFO, and the Psychology and Behavioral Sciences Collection and included articles published between 1995 and 2013. The articles included reported data on studies increasing or decreasing sitter use. Sitter reduction studies showed no increase in fall rates; studies implementing sitters to reduce falls showed conflicting results. Implications include the impact to staffing and nursing practice that results from sitter use, the need for staff education programs, how sitter use can affect patient satisfaction, and the need for additional, more robust research on this topic to determine whether sitter use is evidence-based practice. [Journal of Gerontological Nursing, 40 (5), 24–33.]

Ms. Lang is Medical-Surgical Nurse, Neuroscience/Renal Transplant/ Nephrology Unit, Virginia Mason, Seattle, Washington.

The author has disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Carrie E. Lang, RN, MSN, CNL, 5438 125th Avenue SE, Bellevue, WA 98006; e-mail: Carrie.Lang@gmail.com.

Received: July 19, 2013
Accepted: February 25, 2014
Posted Online: March 19, 2014

Preventing falls in hospitalized older adults is a primary nursing concern. Falls can increase the patient’s length of stay in the hospital, precipitate a transfer to a higher level of care, and lead to discharge to a skilled nursing facility rather than home. Incidence rates for falls of hospitalized patients vary, ranging from 1.3 to 7 falls per 1,000 patient days (He, Dunton, & Staggs, 2012). As of 2008, Medicare no longer reimburses hospitals for the costs of care incurred resulting from a fall.

One nursing intervention currently in use to prevent falls in high-risk patients is to employ staff, often called sitters, to provide constant observation of these patients. Sitters are commonly used in acute care, and a recent survey of nurse managers indicates they are used as a fall prevention intervention 68% of the time (Shever, Titler, Mackin, & Kueny, 2011). A national survey conducted by Worley, Kunkel, Gitlin, Menefee, and Conway (2000) determined that sitter use is typically not billed separately but is included in the cost center as nursing hours per patient day; for this reason, nursing management is under increasing pressure to reduce sitter costs. The purpose of this article is to present a comprehensive review of the literature on sitter use and falls to determine whether using sitters with hospitalized older adults reduces their incidence of falls and make recommendations for clinical practice based on these findings.

Method

A comprehensive review of the literature was conducted using the following databases: CINAHL, MEDLINE, PsycINFO, and the Psychology and Behavioral Sciences Collection (Figure). The search was conducted with the following combinations of search terms: fall* AND sitter*, fall* AND “nursing assistant*,” fall* AND companion*, fall* AND “constant observation.” Articles included for review were those published between 1995 and June 2013 that reported primary data in English. All articles were reviewed by title, and those returned in the search that did not pertain to nursing were excluded. The remaining articles were reviewed by abstract, and those that did not pertain to sitters or fall reduction in the acute care setting were excluded from review. The remaining articles were read and evaluated for inclusion in this review. In addition, reference lists of articles reviewed were checked for additional relevant studies, which were read and included or excluded according to the above criteria. The author graded the articles using a levels-of-evidence and quality rating scale adapted from Stetler et al. (1998). Articles were ranked from Level I to Level VI, determined by the type of evidence used to support the articles’ results. The articles included in this review were all classified as Level IV or V, indicating that they were non-experimental comparative or correlational descriptive studies or program evaluation and quality improvement projects.

Summary of literature search with inclusion/exclusion criteria.

Figure.

Summary of literature search with inclusion/exclusion criteria.

Results

The results of the literature search were compiled and included the population studied, interventions that were implemented, how fall risk was assessed, how sitter use was assessed, and the results of the interventions. Characteristics of the studies are reported in the Table.

Characteristics of Articles Included in the Literature ReviewCharacteristics of Articles Included in the Literature ReviewCharacteristics of Articles Included in the Literature ReviewCharacteristics of Articles Included in the Literature ReviewCharacteristics of Articles Included in the Literature Review

Table:

Characteristics of Articles Included in the Literature Review

Description of Methods

Definitions and Measures. In the studies reviewed, the role of the sitter (also often referred to as a companion) was consistently defined as one having a primary duty to observe patients at high risk for falls. Salamon and Lennon (2003) broadened the scope of the role to include the provision of safety for other people in the care environment, not just the patient being observed. In two studies (Bailey, Amato, & Mouhlas, 2009; Donoghue, Graham, Mitten-Lewis, Murphy, & Gibbs, 2005), researchers made a distinction between sitters employed only to sit and observe patients versus those whose role included providing patient care, cognitive stimulation, or interactive companionship.

The amount of time sitters were used to prevent falls was measured and varied from study to study. Measurements included sitter shifts per month (Rausch & Bjorklund, 2010; Salamon & Lennon, 2003), sitter hours per month (Harding, 2010), sitter full-time equivalents per month (Adams & Kaplow, 2013), total sitter shifts during time period studied (Boswell, Ramsey, Smith, & Wagers, 2001; Spiva et al., 2012), and sitter request rate (Tzeng, Yin, & Grunawalt, 2008). In five studies, the specifics of sitter use were not disclosed by the researchers (Bailey et al., 2009; Donoghue et al., 2005; Giles et al., 2006; Weeks, 2011; Wright, 2006).

An often-cited definition of a “fall” is as follows:

A patient fall is an unplanned descent to the floor with or without injury to the patient. Include falls when a patient lands on a surface where you wouldn’t expect to find a patient. All unassisted and assisted falls are to be included whether they result from physiological reasons (fainting) or environmental reasons (slippery floor). Also report patients that [sic] roll off a low bed onto a mat as a fall.

However, none of the studies reviewed explicitly defined a fall.

Measures used to determine if a patient was at risk for falls varied in the articles reviewed. Measures included the Patient Attendant Assessment Tool (PAAT) score (Tzeng et al., 2008) to assess patient fall risk as a part of a greater tool for determining the need for a sitter; the Royal Melbourne Hospital Risk Assessment Tool (Wright, 2006); the St. Thomas Risk Assessment Tool (Giles et al., 2006); and the Morse Fall Risk Assessment tool (Harding, 2010). In Donoghue et al. (2005), researchers used a fall risk assessment tool developed by their hospital. In three studies, researchers reported that “nursing judgment” was used to assess for patient fall risk (Donoghue et al., 2005; Giles et al., 2006; Tzeng et al., 2008). In more than half the studies reviewed, researchers did not disclose how they determined patient fall risk.

Population. In 11 articles, researchers initiated their interventions solely in acute care settings. In the exception, Salamon and Lennon (2003) implemented interventions in a rehabilitation unit and a skilled nursing unit, both within a hospital. Researchers in one study implemented interventions in multiple hospitals (Adams & Kaplow, 2013); in five studies, researchers implemented hospital-wide interventions (Boswell et al., 2001; Harding, 2010; Rausch & Bjorklund, 2010; Spiva et al., 2012; Weeks, 2011); and in one study, researchers included all hospitalized patients, excluding critical care, obstetrics, and psychiatric units in their interventions (Boswell et al., 2001). In the remaining studies, researchers focused on unit-based interventions. In five of the studies reviewed, researchers either focused their interventions on a 60-and-older population or found that their sitter use was already prevalent among this population (Boswell et al., 2001; Donoghue et al., 2005; Rausch & Bjorklund, 2010; Salamon & Lennon, 2003; Weeks, 2011).

Effect of Sitter Use on Fall Rates

The studies included in this review used two primary types of interventions. In the first group, researchers at the health care agency observed a need for reducing the rate of patient falls and implemented a fall reduction program that included sitters. In the second group, researchers wanted to reduce the number of sitters and their associated costs without increasing the rate of falls in the hospital or unit.

Adding Sitters to Reduce Falls. In three of the studies that employed sitters to reduce falls, researchers found that the fall rates did not decline when sitters were used (Bailey et al., 2009; Boswell et al., 2001; Giles et al., 2006). However, in two studies, researchers found a reduction in falls with sitter use: Donoghue et al. (2005) found an overall 44% reduction in fall rates, and Wright (2006) found a 50% reduction in falls.

Sitter Use Reduction Programs and Falls. In two of the studies where sitter use was decreased (Rausch & Bjorklund, 2010; Weeks, 2011), researchers found that fall rates also decreased. In the remaining five studies, researchers found that fall rates were not affected by a reduction in sitter use (Adams & Kaplow, 2013; Harding, 2010; Salamon & Lennon, 2003; Spiva et al., 2012; Tzeng et al., 2008).

Discussion

Of the 12 studies reviewed, only two (Donoghue et al., 2005; Wright, 2006) correlated a reduction in fall rates with higher utilization of sitters. However, in these studies, the care environment for high-risk fall patients was also modified, potentially diluting the effect sitters had on fall reduction. In addition, the samples for these two studies were small, with interventions implemented on only one unit per hospital, which may have affected the generalizability of their findings. In two studies reviewed, sitter use was implemented and fall rates did not improve. The authors speculated that this could be related to a lack of additional fall reduction strategies, a limited number of hours when sitters were present, falls occurring when sitters stepped away from their posts, or inconsistent criteria for sitter use.

Although placing sitters with patients at high risk for falls did not always reduce fall rates, a review of sitter-use reduction studies consistently demonstrated that a decrease in sitter use did not correspond with an increase in patient falls. It is important to note that, in addition to reducing the number of sitters used, most studies also implemented multifaceted fall risk reduction strategies. It is not clear which of the sitter alternatives helped most to reduce fall risk; quality improvement projects often focus on a broad range of interventions, and those reviewed for the current study were no exception. Strategies implemented to replace the use of sitters included using bed and chair alarms, moving the patient closer to the nursing station, reviewing medication lists, implementing sleep protocols, providing low beds and non-skid floor mats, posting fall-risk signs, using non-skid socks/slippers, engaging patients in diversional activities (e.g., card games, conversation, music, activity aprons), providing nightlights, providing back rubs or other relaxation techniques, encouraging family support, implementing intentional rounding (i.e., toileting, positioning, pain control), wrapping or hiding lines/drains/tubes, and reviewing invasive medical devices (e.g., indwelling catheters, intravenous lines) for discontinuation (Adams & Kaplow, 2013; Salamon & Lennon, 2003; Spiva et al., 2012; Tzeng et al., 2008; Weeks, 2011). These interventions, when combined with nursing oversight and frequent reassessment of sitter use, resulted in decreased sitter use that did not adversely affect overall fall rates.

Limitations

Despite the prevalence of sitter use to reduce falls in acute care settings, there is a lack of controlled trial research in the literature correlating sitter use to fall reduction. None of the studies reviewed herein were controlled trials; most studies examined quality improvement projects or descriptive data, which limits the validity of this review. Many interventions were implemented on single nursing units, so the samples were relatively small. Because of the diversity of patient populations studied, generalizability of the findings of this literature review to older adult populations is limited. Another limitation is that this review is restricted to sitter studies and does not include sitter study results that are part of more comprehensive overall studies. Finally, it is possible that expanding the search criteria to include non-English language articles may improve the quality of this review.

Implications for Practice

Clinical Nursing Considerations

As the research reviewed does not reach a consensus regarding fall reductions and sitter use, nurses will continue to rely on their critical thinking skills to promote patient safety in regard to sitter use. When a nurse delegates tasks to assistive personnel, the nurse remains responsible for the care of the patient. Such is the case when sitters are used to observe patients and ensure their safety. In consideration for patient safety, nurses should not only follow the fall assessment and risk policies and procedures outlined by their employers, but also institute “nursing judgement” in assessing for patient fall risk. For example, if sitters are being pulled from existing staff, patients who do not require sitters may be at risk for harm related to lower staffing ratios. Nurses should increase their awareness with patients in this situation. If sitter use does not reduce the rate of falls, floor nursing staff should advocate for the implementation of alternative fall risk reduction interventions in their workplaces, such as bed alarms or placing high fall-risk patients closer to the nursing station. Additionally, nursing staff and administrators should see that tools such as the PAAT score, Morse Fall Risk Assessment tool, or Hendrich II Fall Risk Model (Hendrich, Bender, & Nyhuis, 2003) are consistently and objectively used to help predict and prevent future falls. Nursing staff educators may provide ongoing training to ensure that staff are up-to-date with policies and procedures, and that they are implementing them effectively.

Patient and Family Satisfaction

Three of the studies reviewed showed patients’ satisfaction with the care they received increased with sitter use (Boswell et al., 2001; Donoghue et al., 2005; Giles et al., 2006). Family members may feel more at ease with a one-on-one sitter, so any sitter reduction program should implement robust patient and family education components to explain alternative methods to reduce fall risk and to reinforce the hospital’s commitment to patient safety. Although several of the studies reviewed used family members as an alternative to sitters (Salamon & Lennon, 2003; Spiva et al., 2012; Tzeng et al., 2008; Weeks, 2011), Tzeng, Yin, Tsai, Lin, and Yin (2007) demonstrated that family presence alone did not prevent patient falls. As such, administrators and nursing staff should not rely on family presence as a singular intervention to prevent patients from falling, as this could expose care facilities to the possibility of liability issues.

Considerations for Future Research

Because of the prevalence of sitter use in acute care and the concurrent need for nursing units to use their funds in the most efficient manner possible, it seems critical that additional research on this topic be conducted. Is using sitters to prevent falls actually evidence-based practice or simply a stop-gap attempt to minimize restraint use? As stated above, the studies reviewed herein were not randomized controlled trials. Additionally, there was a general lack of agreement or definition in the studies of what constitutes a fall and how fall risk is measured. None of the studies reviewed addressed whether their results were influenced by the Hawthorne Effect; this experimental design problem manifests when the participants’ behavior is altered by the knowledge that they are being observed (Polit & Beck, 2008).

Larger studies with controls and clearer measurements and definitions should be conducted to further evaluate sitter effectiveness to reduce falls, as well as the sustainability of sitter reduction programs. Future studies should detail the number of patients of the total patient population deemed to be high fall-risk and use a validated metric to determine the level of risk. Randomized control groups should be created to place some high-risk patients with sitters in the control group, whereas other fall reduction strategies be used with the experimental group. These randomized groups will require a large enough number of patients to balance the two groups for confounding variables (e.g., acuity of illness, age, gender, medication list, baseline functional status) to support the internal validity of the study. Sitters used during the trial period should all undergo the same training and provide the same interventions to reduce the differences in patient outcomes, which could be attributed to the individual acting as sitter. Nursing and medical team staff should be given clear guidance as to when sitters should be implemented and when they should be discontinued to further strengthen the study’s validity. Increasing the rigor of future research on this topic will provide better guidance to nursing units wishing to enhance patient safety while reducing costs.

Summary

This literature review adds further insight into the discussion about whether using sitters in an acute care setting can reduce falls among patients. Implementation of sitters alone does not reduce the rate of falls, but sitters may be used as part of a larger fall prevention program. Oversight for sitter use, to include the reevaluation of sitter need every shift, is important, whether implementing a program to introduce sitters or working to reduce the number of sitters used. Formal protocols for sitter utilization may prompt floor nurses to consider whether alternative fall risk measures may be more appropriate. When sitters are used, formal training on the scope and expectations of the role, to include cognitive stimulation interactions with patients, is essential to provide safe and effective care for the patients they are assigned to supervise. Further rigorous research into this topic is required to make evidence-based determinations as to the usefulness of sitters in preventing falls.

References

  • Adams, J. & Kaplow, R. (2013). A sitter-reduction program in an acute health care system. Nursing Economics, 31, 83–89.
  • Bailey, M., Amato, S. & Mouhlas, C. (2009). A creative alternative for providing constant observation on an acute-brain-injury unit. Rehabilitation Nursing, 34, 11–16. doi:10.1002/j.2048-7940.2009.tb00242.x [CrossRef]
  • Boswell, D.J., Ramsey, J., Smith, M.A. & Wagers, B. (2001). The cost-effectiveness of a patient-sitter program in an acute care hospital: A test of the impact of sitters on the incidence of falls and patient satisfaction. Quality Management in Health Care, 10, 10–16. doi:10.1097/00019514-200110010-00003 [CrossRef]
  • Donoghue, J., Graham, J., Mitten-Lewis, S., Murphy, M. & Gibbs, J. (2005). A volunteer companion-observer intervention reduces falls on an acute aged care ward. International Journal of Health Care Quality Assurance, 18, 24–31. doi:10.1108/09526860510576947 [CrossRef]
  • Ganz, D.A., Huang, C., Saliba, D., Shier, V., Berlowitz, D., Lukas, C.V. & Neumann, P. (2013). Preventing falls in hospitals: A tool-kit for improving quality of care (AHRQ Publication No. 13-0015-EF). Retrieved from http://www.ahrq.gov/professionals/systems/long-term-care/resources/injuries/fallpxtoolkit/fallpxtoolkit.pdf
  • Giles, L.C., Bolch, D., Rouvray, R., McErlean, B., Whitehead, C.H., Phillips, P.A. & Crotty, M. (2006). Can volunteer companions prevent falls among inpatients? A feasibility study using a pre-post comparative design. BMC Geriatrics, 6, 11. doi:10.1186/1471-2318-6-11 [CrossRef]
  • Harding, A.D. (2010). Observation assistants: Sitter effectiveness and industry measures. Nursing Economics, 28, 330–336.
  • He, J., Dunton, N. & Staggs, V. (2012). Unit-level time trends in inpatient fall rates of US hospitals. Medical Care, 50, 801–807. doi:10.1097/MLR.0b013e31825a8b88 [CrossRef]
  • Hendrich, A.L., Bender, P.S. & Nyhuis, A. (2003). Validation of the Hendrich II Fall Risk Model: A large concurrent case/control study of hospitalized patients. Applied Nursing Research, 16, 9–21. doi:10.1053/apnr.2003.016009 [CrossRef]
  • Polit, D.F. & Beck, C.T. (2008). Nursing research: Generating and assessing evidence for nursing practice (8th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
  • Rausch, D.L. & Bjorklund, P. (2010). Decreasing the costs of constant observation. Journal of Nursing Administration, 40, 75–81. doi:10.1097/NNA.0b013e3181cb9f56 [CrossRef]
  • Salamon, L. & Lennon, M. (2003). Decreasing companion usage without negatively affecting patient outcomes: A performance improvement project. Medsurg Nursing, 12, 230–236.
  • Shever, L.L., Titler, M.G., Mackin, M.L. & Kueny, A. (2011). Fall prevention practices in adult medical-surgical nursing units described by nurse managers. Western Journal of Nursing Research, 33, 385–397. doi:10.1177/0193945910379217 [CrossRef]
  • Spiva, L., Feiner, T., Jones, D., Hunter, D., Petefish, J. & VanBrackle, L. (2012). An evaluation of a sitter reduction program intervention. Journal of Nursing Care Quality, 27, 341–345. doi:10.1097/NCQ.0b013e31825f4a5f [CrossRef]
  • Stetler, C.B., Brunell, M., Giuliano, K.K., Morsi, D., Prince, L. & Newell-Stokes, V. (1998). Evidence-based practice and the role of nursing leadership. Journal of Nursing Administration, 28(7–8), 45–53. doi:10.1097/00005110-199807000-00011 [CrossRef]
  • Tzeng, H.M., Yin, C.Y. & Grunawalt, J. (2008). Effective assessment of use of sitters by nurses in inpatient care settings. Journal of Advanced Nursing, 64, 176–183. doi:10.1111/j.1365-2648.2008.04779.x [CrossRef]
  • Tzeng, H.M., Yin, C.Y., Tsai, S.L., Lin, S. & Yin, T.J. (2007). Patient falls and open visiting hours: A case study in a Taiwanese medical center. Journal of Nursing Care Quality, 22, 145–151. doi:10.1097/01.NCQ.0000263104.08096.f8 [CrossRef]
  • Weeks, S.K. (2011). Reducing sitter use: Decision outcomes. Nursing Management, 42(12), 37–38. doi:10.1097/01.NUMA.0000407582.12602.21 [CrossRef]
  • Worley, L.L., Kunkel, E.J., Gitlin, D.F., Menefee, L.A. & Conway, G. (2000). Constant observation practices in the general hospital setting: A national survey. Psychosomatics, 41, 301–310. doi:10.1176/appi.psy.41.4.301 [CrossRef]
  • Wright, K. (2006). Falling head over heels: Reducing falls in high risk neurosurgical inpatients with the implementation of a ‘high risk falls room.Australasian Journal of Neuroscience, 18, 3–7.

Characteristics of Articles Included in the Literature Review

Study/CountryDesign/Method (Quality/ Evidence Level)Population, Sample, and InterventionFall Risk MeasureFalls MeasureSitter Use MeasureOutcomes and Results
Boswell, Ramsey, Smith, & Wagers (2001) United StatesRetrospective epidemiological (V)Patients from seven inpatient medical and surgical units in one 641-bed hospital. Critical care, obstetrics, and psychiatric units were excluded. Data collected from a 21-month period. Sitters were implemented to reduce falls and increase patient satisfaction scores.NAData based on retrospective occurrence reportingTotal number of 8-hour sitter shifts during 21-month periodPatient falls increased by an effect size of 0.0019 per 8-hour sitter shift based on a Poisson regression model for repeat events.
Salamon & Lennon (2003) United StatesPre-post comparative (V)Patients ages 24 to 102 (mean = 69 years). One subacute and one rehabilitation unit in a 1,000-bed hospital. One year prior to intervention measured against 1 year of intervention. Process improvement project: (1) implementation of a protocol where sitter requests were approved only by nursing management; (2) staff educated on new protocol and alternative interventions.NATotal falls per yearNumber of sitter shifts worked per monthSitter use was reduced; fall rates were not affected.
Donoghue, Graham, Mitten-Lewis, Murphy, & Gibbs (2005) AustraliaProspective descriptive (IV)Patients on an acute aged care ward at a teaching hospital. Highest risk patients were placed in one of two four-bed “high fall risk” rooms near the nursing station. Volunteers were recruited and trained to provide constant observation of patients at risk for falls. One volunteer stayed in the high-risk room and provided some assistance (e.g., meal tray set up) and cognitively stimulating interactions (e.g., playing cards); the other volunteer walked the unit halls to find wandering or wobbling patients. Volunteers would alert nursing staff if patients were becoming agitated or engaging in a fall-risk behavior. Volunteers worked 2-hour shifts from 8:00 a.m. to 8:00 p.m.Falls risk tool developed by hospital, nursing judgmentFalls per 1,000 bed daysNAPrior to intervention, mean falls rate was 15.6 per 1,000 bed days (median = 14.5, SD = 6.5, range = 5.2 to 29.3). Post-intervention mean falls rate was 8.8 per 1,000 bed days (median = 9.8, SD = 3, range = 1.1 to 13.2). Reduction in falls was 44% (Fisher’s exact chi square, p < 0.000; odds ratio = 0.56; 95% CI [0.45, 0.68]).
Giles et al. (2006) AustraliaPre-post comparative (IV)Patients at high risk for falls were placed in four-bed “safety bays” at two hospitals. At one site, the safety bay was located in a general medical ward, at the second site, the safety bay was located within a ward that accommodated patients with dementia and behavioral problems. Volunteer sitters staffed the safety bays from 9:00 a.m. to 5:00 p.m., Monday through Friday.STRATIFY at first site, clinical judgment at second siteFalls per OBDNABaseline period: 70 falls in 4,828 OBDs (14.5 falls per 1,000 OBD); implementation period: 82 falls in 5,300 OBDs (15.5 falls per 1,000 OBD). No falls occurred with patients in safety bays while volunteers were present. The incidence of falls outside the safety bay did not decrease; the incidence of falls inside the safety bay when volunteers were present did not decrease. Incident rate ratio for falls during implementation period versus baseline was 1.07, CI = 95%.
Wright (2006) AustraliaRetrospective descriptive (V)Patients in a 30-bed neurosurgical ward of an acute care hospital. A four-bed “high risk falls room” was created and staffed 24 hours per day, 7 days per week by a nursing assistant who acted as a sitter.Royal Melbourne Hospital Risk Assessment ToolFalls per monthNAIn the baseline period, the rate of falls was 6.5 per month. Within 6 months of implementation of the intervention, the incidence of falls on the ward had decreased 50%.
Tzeng, Yin, & Grunawalt (2008) United StatesRetrospective descriptive (IV)Two, 32-bed, acute adult medical units. Data from 13 months prior to implementation of the intervention were compared with data 5 months following intervention initiation. Units piloted the PAATa intended to reduce sitter use.PAAT score or nursing judgmentFalls per 1,000 patient daysSitter request rate, sitter request/sitter implementation rateIndependent t tests were used to compare fall rates pre- and post-implementation: overall falls decreased but not by a statistically significant amount. Injuries from falls increased on Unit 1 (t = −2.79, p = 0.01, pre-PAAT mean = 0.25, post-PAAT mean = 0.59); Pearson and Spearman correlation analyses were performed between sitter use and implementation rates. For Unit 2, there was a correlation between higher sitter request/implementation rates and higher fall rates (Pearson r = 0.49, p = 0.04).
Bailey, Amato, & Mouhlas (2009) United StatesPre-post comparative (IV)Patients in a 21-bed acute brain injury rehabilitation unit, ages 13 and older, 80% admitted with traumatic brain injuries. On average, 21% of patients on the unit required constant observation. A “day room” was created in the unit, and patients were encouraged to attend cognitively stimulating activities in this room. The sitter role was redesigned to facilitate cognitive stimulation through games and conversation. One sitter was placed in the day room. On average, 59% of patients on the unit were included in the intervention between 8:00 a.m. and 4:00 p.m.NAFalls per 1,000 patient daysNAFall rates: before implementation, 4.06 falls per 1,000 patient days; after implementation, 4.50 falls per 1,000 patient days.
Harding (2010) United StatesPre-post comparative (V)Inpatients and ED patients at a Massachusetts hospital. Patient fall rate during the year of implementation of the sitter reduction project compared with patient falls in the months prior to implementation.Morse Fall Risk AssessmentMonthly falls per 1,000 patient daysProductive sitter hours per monthMonthly fluctuations occurred in rate of falls, which did not correlate with the number of sitter hours used to prevent falls or the number of sitter hours when compared against the average daily census.
Rausch & Bjorklund (2010) United StatesRetrospective descriptive (V)Patients hospital-wide in an 800-bed hospital. A PLN program was implemented. PLNs were consulted by nursing staff regarding sitter use Monday through Friday.NAPatient falls per monthTotal 8-hour sitter shifts per month50% decrease in sitter use over 1 year beginning with implementation. During the same period, hospital-wide falls declined by 25%.
Weeks (2011) United StatesRetrospective descriptive (V)Patients in a 222-bed community hospital. Data collected for 21 months prior to implementation of sitter use reduction plan were compared with data 42 months post-implementation. Hospital implemented a sitter use reduction program: physicians no longer able to place orders for sitters, and sitters used only for patients with involuntary commitment, suicidal ideation/ attempt, or behavioral restraints.NAFalls per patient dayNAPre-implementation 0.00543 falls per patient day vs. 0.00436 falls per patient day post implementation. Pre-implementation 0.0000652 fractures per patient day vs. 0.0000581 fractures per patient day post-implementation.
Spiva et al. (2012) United StatesPre-post comparative (IV)633-bed community acute-care hospital with five critical care units, two step-down units, and 11 medical-surgical units. Data collected June-December pre-intervention and June-December post-intervention. Hospital implemented a sitter reduction program. Staff provided tools and training on alternatives to sitter use, including moving patient closer to the nursing station, rotating staff to provide one-to-one care, or grouping two patients requiring observation with the same sitter.NATotal patient falls in pre and post periods; rate of falls.Total sitter hoursPost-implementation, sitter hours decreased from 47,218 to 17,208. Overall falls decreased from 199 to 197. Overall fall rates decreased from 2.45 to 2.39; however, neither fall change was statistically significant. Care setting fall rates were mixed post-implementation: critical care, pre 1.18, post 1.38; step-down, pre 4.35, post 2.59; medical-surgical, pre 2.68, post 2.81. Sitter hours were reduced by a statistically significant amount in all three settings (t = 5.59, p = 0.001).
Adams & Kaplow (2013) United StatesPre-post comparative (V)All patients in a health care system comprising four hospitals with approximately 1,400 inpatient beds. Falls incidence measured for 1 year prior to implementation and for 2 years post-implementation. Patients on suicide watch, those with neurology implants, or those in restraints or in seclusion were excluded. A sitter reduction program was implemented. Sitter role was eliminated and sitter staff were retrained as nurse technicians; fall-risk identification was emphasized; environmental hazards were fixed; and new fall-reduction equipment was purchased.Morse Fall Risk AssessmentFalls per 1,000 patient daysSitter FTEs per monthSitter use decreased and remained low. Fall rates did not change.

Keypoints

Lang, C.E. (2014). Do Sitters Prevent Falls? A Review of the Literature. Journal of Gerontological Nursing, 40(5), 24–33.

  1. Few published studies show a link between increased sitter use and a decrease in falls in hospitalized patients.

  2. Sitter-reduction studies show no link between increased falls and decreased sitter use; however, when sitter use was decreased, alternative fall-prevention measures were implemented.

  3. Whether or not sitters are used, nurses will continue to have to rely on their judgment to prevent falls in hospitalized patients, especially when support staff are redeployed as sitters, limiting their availability to help prevent falls in other unit patients.

  4. If sitter reduction measures are implemented in hospitals, clear guidelines for sitter use and discontinuation should be provided, as well as formal education for sitters regarding the scope and expectations of the role.

Keypoints

10.3928/00989134-20140313-01

Sign up to receive

Journal E-contents