Journal of Psychosocial Nursing and Mental Health Services

CNE Article 

Making Fall Risk Assessment Clinically Relevant in an Adult Psychiatric Setting

Lilly Mathew, PhD, RN; Darlene Steigman, RN-BC, PMHNP-BC; Denise Driscoll, RN-BC, CARN, PMHCNS-BC, NPP; Judith Ann Moran-Peters, DNSc, RN, NE-BC; Ira M. Fischer, MBA, MA; Patricia Cordle, RN-BC, MA; Vanessa Marie Bishop Hyde, BS; Sarah Eckardt, MS

Abstract

The purpose of this non-experimental descriptive study was to measure psychiatric clinical nurses' (N = 25) perceptions of the Edmonson Psychiatric Falls Risk Assessment Tool© (EPFRAT) compared to the Morse Fall Scale (MFS) and to evaluate patient falls with injury rates 12 months before and after the study. The setting was a 27-bed, adult psychiatric unit in a community-based teaching hospital located in the Northeast region of the United States. The EPFRAT and MFS were used to assess fall risk in 216 patients over 3 months. Findings indicated that the EPFRAT was more user-friendly and relevant; improved nurses' clinical judgment in identifying high-risk patients; and nurses were supportive toward changing practice from using the MFS to EPFRAT for fall risk assessment. Falls with injury rates decreased by 0.52 per 1,000 patient care days post-implementation of the EPFRAT. [Journal of Psychosocial Nursing and Mental Health Services, 58(2), 21–26.]

Abstract

The purpose of this non-experimental descriptive study was to measure psychiatric clinical nurses' (N = 25) perceptions of the Edmonson Psychiatric Falls Risk Assessment Tool© (EPFRAT) compared to the Morse Fall Scale (MFS) and to evaluate patient falls with injury rates 12 months before and after the study. The setting was a 27-bed, adult psychiatric unit in a community-based teaching hospital located in the Northeast region of the United States. The EPFRAT and MFS were used to assess fall risk in 216 patients over 3 months. Findings indicated that the EPFRAT was more user-friendly and relevant; improved nurses' clinical judgment in identifying high-risk patients; and nurses were supportive toward changing practice from using the MFS to EPFRAT for fall risk assessment. Falls with injury rates decreased by 0.52 per 1,000 patient care days post-implementation of the EPFRAT. [Journal of Psychosocial Nursing and Mental Health Services, 58(2), 21–26.]

Each year between 700,000 and 1,000,0000 people in the United States fall during hospitalization (Agency for Healthcare Research and Quality, 2018). Approximately 30% to 50% of patients sustain injuries, prolonging hospital stays by 6.3 days and increasing the cost of care by $14,000 per incident (The Joint Commission, 2015). Falls among hospitalized patients can lead to fractures and intracranial hemorrhages (Kobayashi et al., 2017).

In a recent study, falls among older psychiatric patients were found to be common globally, predicting that >24 million patients would experience at least one fall in their lifetime (Rao et al., 2019). Falls were more frequent in psychiatric (1.95) and psychogeriatric (3.19) units compared to general (0.76) units per 1,000 occupied bed days (Scanlan, Wheatley, & McIntosh, 2012). According to Powell-Cope et al. (2014), falls on inpatient psychiatric units are understudied compared to medical-surgical and long-term care settings. Hospitalized patients with cognitive impairment and depression are at higher risk for sustaining injuries among inpatients age ≥60 (Yang & Chen, 2018). Patient falls on behavioral health units were identified to be a commonly occurring adverse event among 9,780 safety reports generated from a national database between 2015 and 2016 (Mills, Watts, Shiner, & Hemphill, 2018). Conditions such as cognitive impairment, use of antipsychotic medications and sedative agents, and hospital policies related to staffing, transfers, and use of restraints were also identified as factors contributing to falls in hospital settings (Watson, Salmoni, & Zecevic, 2019). Falls are recognized as a high-risk issue in inpatient psychiatric settings due to the combination of mental status changes, independent self-care, freedom of ambulation, and freedom from restraint. Falls with injuries among psychiatric patients prolong the length of stay and negatively impact the treatment plan.

Among many fall prevention measures, the use of an appropriate fall risk assessment tool is essential. Two fall risk assessment tools identified in the literature that are specific to psychiatric inpatients are the Wilson-Sims Fall Risk Assessment Tool (WSFRAT; Van Dyke, Singley, Speroni, & Daniel, 2014) and Edmonson Psychiatric Falls Risk Assessment Tool© (EPFRAT; Edmonson, Robinson, & Hughes, 2011). Factors assessed using WSFRAT include age, mental status, physical status, elimination status (i.e., continent/incontinent), sensory impairments, gait or balance, history of falls, medications (e.g., mood stabilizers, benzodiazepine agents, narcotic agents, sedative/hypnotic drugs, antipsychotic agents), and detoxification protocol (Van Dyke et al., 2014). The EPFRAT captures specific factors related to falls among psychiatric patients, which include mental status, use of medications (cardiac and psychotropic), ambulation/balance, and sleep disturbances. The EPFRAT was found to be more sensitive in assessing fall risk among the psychiatric population (0.63) compared with the Morse Fall Scale (MFS; Morse, 2008) (0.49) (Edmonson et al., 2011), a generic fall risk assessment tool.

Background

The current study was initiated in response to an alarming increase of falls with injury on a 27-bed inpatient adult psychiatric unit. The setting was a community-based teaching hospital located in the Northeast region of the United States. A retrospective chart review of patient cases (N = 14) prior to initiation of the study found the use of antihypertensive and psychotropic medications in high percentages (96%) among patients who sustained injuries from falls. The literature supports that the use of psychotropic agents are linked to falls among adult psychiatric patients (Lenze, 2018), and adjusting psychiatric medications may reduce fall risk (University of Michigan, 2017). Subsequently, changes were made in the standard times of administration of antihypertensive and psychotropic medications (6 hours apart). In addition, practices used for the evaluation of fall risk assessment were examined.

A traditional hospital-wide nursing practice was to use the MFS (Morse, 2008) to assess fall risk across all patient populations, including psychiatric patients. However, the MFS does not capture the use of psychotropic and antihypertensive medications. Using generic fall risk assessment tools and not population-specific tools was recognized as a limitation in current practice (Wynaden, Tohotoa, Heslop, & Omari, 2016). Therefore, importance was placed in finding a valid and reliable tool that was sensitive in measuring fall risk among adult psychiatric patients taking high-risk medications, namely the combination of psychotropic and antihypertensive agents. To manage potential “nurse resistance,” which has been identified in the literature as a barrier to implementing evidence-based practice change (Camargo et al., 2018), the current authors believed it was essential to engage clinical nurses in the study by providing them an opportunity to use the EPFRAT and capture their perceptions on the proposed practice change.

The EPFRAT was considered because it captured the use of psychotropic medications as well as cardiac medications. Although the WSFRAT also includes the assessment of psychotropic medications, it does not include cardiac medications.

Conceptual Framework

Lewin's Change Model (Manchester et al., 2014) guided the research study. Lewin's model looks at change as a process with distinct stages. The process starts with creating the perception that a change is needed, to creating motivation for the change to be possible, and then to finally solidifying the change into new practice (Mitchell, 2013). The increasing fall injury rates on the unit created a perception that it was necessary to evaluate current practices concerning fall risk assessment. Evaluation of current practices indicated the need to bring a practice change of using a valid and reliable fall risk assessment tool specific to the inpatient psychiatric population. Figure 1 demonstrates the practice change process that was undertaken in the current study. However, before implementing the practice change, the end-users were provided education on the EPFRAT and given an opportunity to engage in the unit-based study.

Practice change process.

Figure 1.

Practice change process.

Purpose and Aims

The purpose of the current study was to capture the perceptions of psychiatric clinical nurses on the use of the EPFRAT versus MFS and measure fall injury rates before and after the study. The aims of the study were to: (a) measure the perceptions of psychiatric nurses on using the EPFRAT vs. MFS in regard to user-friendliness, relevance, supportiveness, and clinical judgment; and (b) compare fall injury rates 12 months before and after study implementation.

Method

A non-experimental descriptive study was designed. In collaboration with the information technologist, the EPFRAT was built into the Allscripts® electronic medical record (EMR) system. Participants used the EPFRAT and MFS simultaneously to assess fall risk among all admitted patients during the 3-month pilot period. The total number of admitted patients during the study period was 216 based on EMR daily census report. Institutional Review Board approval was obtained.

Participants

A convenience sample of psychiatric clinical nurses (N = 25) was recruited for the study. Recruitment was done via e-mail and by posting flyers on the unit bulletin board. Participation in the study was voluntary.

Data Collection

After 3 months of using the EPFRAT and MFS simultaneously to assess fall risk, participants were asked to rate their perceptions of the EPFRAT. A Likert-type scale was designed to measure four items: user-friendliness, relevance, supportiveness, and clinical judgment. User-friendliness was defined as something that enables the user to interact in a meaningful and conversationally fluent manner (Coombs, 2005). Relevance was defined as something that is relevant to a task if it increases the likelihood of accomplishing the goal (Birger, 2010). Supportiveness was defined as the user's agreement of the proposed practice change, and clinical judgment was defined as the ability to make logical decisions to whether the action is correct or not (The Free Dictionary, 2019). The scale enabled participants to rate each item as strongly disagree (1), disagree (2), undecided (3), agree (4), and strongly agree (5). The questionnaire was given in a paper-and-pencil format to all participants, and questionnaires were returned in a sealed envelope in a drop-box. In addition, a comment box at the end of the questionnaire allowed participants to write any comments they may have regarding the assessment tools. The questionnaire was anonymous, and no identifying information was obtained.

Data Analysis

Responses to the questionnaire were analyzed using SPSS version 24.0 and graphs were generated using Microsoft® Excel®. Descriptive statistics were reported as means and standard deviations.

Results

Scale Comparison

Mean user-friendless was 3.96 (SD = 0.978), relevance was 4.29 (SD = 0.806), supportiveness was 4.08 (SD = 0.909), and clinical judgment was 4.00 (SD = 1.041), indicating nurses' perceptions of the EPFRAT were positive (Table 1). Reliability statistics indicated Cronbach's alpha = 0.92, which demonstrated high internal consistency.

Descriptive Statistics of Nurses' Perceptions of Using the Edmonson Psychiatric Fall Risk Assessment Tool

Table 1:

Descriptive Statistics of Nurses' Perceptions of Using the Edmonson Psychiatric Fall Risk Assessment Tool

Frequencies were obtained on the EPFRAT ratings across four items (Table 2). Agreed and strongly agreed and disagree and strongly disagreed were grouped together for analyzing consensus among participants. Based on findings, 80% of participants agreed that the EPFRAT was user-friendly, 87.5% rated it as clinically relevant, 76% reported that it increased clinical judgment in assessing fall risk patients, and 80% supported the practice change of using the EPFRAT.

Nurses' Perceptions of the Edmonson Psychiatric Falls Risk Assessment Tool (EPFRAT) and Morse Fall Scale (MFS) (N = 25)

Table 2:

Nurses' Perceptions of the Edmonson Psychiatric Falls Risk Assessment Tool (EPFRAT) and Morse Fall Scale (MFS) (N = 25)

In addition, six comments were received from participants. Most comments were positive regarding the EPFRAT, indicating that it was helpful, appropriate, relevant, and preferred over the MFS. However, there was one negative comment regarding the scoring of the EPFRAT. One participant believed it was redundant to use two fall risk assessment tools at the same time. Direct quotes from participants are provided as evidence:

“The Morse Scale doesn't help in assessing our adult psychiatric inpatients. The EPFRAT tool is more appropriate and is a truer picture”; “Please keep EPFRAT so much more relevant to our patient population!! Love it!”; “I definitely prefer this [EPFRAT] over the Morse”; “It is redundant to have it done on the A & I [assessment & intervention] and do the Edmonson, just pick one”; “Like it better than Morse”; and “Questions are more relevant [on EPFRAT] but scoring is not.”

Fall Injury Rates

Fall injury rates were calculated as occurrences per 1,000 patient care days. All falls with injury occurred on the unit. Falls with injury rates were obtained using Midas (2019), a health care analytics software that generates clinical quality measures, for 12 months before and after the study period. Average fall injury rate 12 months before the study was 1.06 per 1,000 patient care days and 12 months after the study was 0.54 per 1,000 patient care days. The overall fall injury rate decreased by 0.52 per 1,000 patient care days. The results indicated a downward trend in falls with injuries (Figure 2).

Fall injury rates per 1,000 patient care days before and after the 1-year study period.

Figure 2.

Fall injury rates per 1,000 patient care days before and after the 1-year study period.

Discussion

Inpatient psychiatric patients are a unique population with an increased risk for falling and sustaining injuries. Assessing patients for fall risk using a psychiatric-specific falls risk assessment tool, such as the EPFRAT, is valuable. The EPFRAT has been identified as a better predictor of falls than other tools in psychiatric populations (McMinn, Booth, Grist, & O'Brien, 2016). The current findings also indicate that using the EPFRAT may decrease fall injury rates on a unit. Changing practice from using a generic tool to a psychiatric-specific, evidence-based tool, such as the EPFRAT, is more clinically relevant. Based on the results of the current study, a practice change of using the EPFRAT was implemented hospital-wide, in all psychiatric units.

The literature suggests that “inclusion” is essential for practice change (Watkins, Dewar, & Kennedy, 2016). The current study adds to the evidence that the inclusion of clinical nurses in unit-based studies is important to implement evidence-based practice change for improved patient outcomes without experiencing nurse resistance. Findings also contribute that the EPFRAT is user-friendly, clinically relevant, and improves nurses' clinical judgment in identifying high-risk patients. Psychiatric clinical nurses supported the practice change from using the generic MFS to the psychiatric-specific, evidence-based EPFRAT.

Limitations

The current study was conducted on one clinical unit in one hospital setting based on convenience with a small sample. However, this study can serve as a base on which future studies can be built to make fall risk assessment clinically relevant in inpatient psychiatric settings for decreasing fall injury rates. Another limitation to consider is the wordings used in the survey questions might have contributed to negative skewness. Therefore, the authors suggest a revision of questions, with some answers in the reverse order to prevent skewness.

Conclusion

Implementation of a psychiatric-specific, evidence-based fall assessment tool, such as the EPFRAT, has the potential to impact patient outcomes positively and may decrease fall injury rates among inpatient psychiatric patients. It is important to use fall risk assessment tools that are specific to the specialty area and that capture factors related to falls. It is valuable to obtain nurses' perceptions before implementing a proposed change, as they are the end-users. When nurses are engaged as participants in the actual decision-making process, the transition from traditional to evidence-based practice can occur with less nurse resistance and have a positive impact on patient outcomes.

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Descriptive Statistics of Nurses' Perceptions of Using the Edmonson Psychiatric Fall Risk Assessment Tool

ItemnMean (SD) (Range)
User-friendliness253.96 (0.978) (1 to 5)
Relevance244.29 (0.806) (2 to 5)
Supportiveness254.08 (0.909) (2 to 5)
Clinical judgment254.00 (1.041) (1 to 5)
Valid n (listwise)24

Nurses' Perceptions of the Edmonson Psychiatric Falls Risk Assessment Tool (EPFRAT) and Morse Fall Scale (MFS) (N = 25)

Questionn (%)
Strongly Disagree (1)Disagree (2)Undecided (3)Agree (4)Strongly Agree (5)
User-friendliness
  EPFRAT is more user-friendly in assessing fall risk among adult inpatient psychiatric population.1 (4)1 (4)3 (12)13 (52)7 (28)
Relevancea
  EPFRAT is more relevant in assessing fall risk among adult inpatient psychiatric population.01 (4)2 (8)10 (40)11 (44)
Supportiveness
  I support the use of EPFRAT to assess fall risk among adult psychiatric patients versus the MFS.02 (8)3 (12)12 (48)8 (32)
Clinical Judgment
I was able to better identify adult psychiatric patients who are at a higher risk of falling with the EPFRAT.1 (4)1 (4)4 (16)10 (40)9 (36)
Authors

Dr. Mathew is Nurse Researcher/Statistician, Ms. Steigman is Staff Nurse, Ms. Driscoll is AVP Behavioral Health, Dr. Moran-Peters is Coordinator–Nursing Research, Mr. Fischer is Applications Analyst, Information Services, Ms. Cordle is Registered Nurse, Ms. Bishop Hyde is Mental Health Technician, and Ms. Eckardt is Nursing Statistician, Mather Hospital Northwell Health, Port Jefferson, New York. Dr. Mathew is also Associate Professor of Nursing Informatics, CUNY School of Professional Studies, and Associate Professor, CUNY Graduate Center, New York; Ms. Steigman is also Consultation & Liaison Psychiatric Nurse Practitioner, St. Charles Hospital, Port Jefferson, New York.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

The authors acknowledge Marie E. Mulligan, PhD, RN, CNOR, NEA, CNO and Vice President for Nursing, Mather Hospital Northwell Health, for her constant support in promoting nursing research; Brandy Feliu, MSN, RN, AVP, for nursing professional development for supporting and implementing practice change; and all nursing staff on 2 West adult psychiatric unit of Mather Hospital Northwell Health.

Address correspondence to Lilly Mathew, PhD, RN, Nurse Researcher/Statistician, Mather Hospital Northwell Health, Nursing Administration, 75 North Country Road, Port Jefferson, NY 11777; e-mail: LMathew12@northwell.edu.

Received: May 24, 2019
Accepted: August 23, 2019

10.3928/02793695-20191106-01

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