The impact of sustaining an in-patient fall: A mixed methods study

The purpose of this research was to investigate and describe the impact on a patient of falling in an acute hospital setting. Falling in hospital can result in a variety of adverse outcomes for the patient, including injury. The literature reveals a fall in hospital can increase the financial burden to the individual and the health care system and can result in increased hospital length of stay (LOS), disability or death. Sustaining a fall can also have a significant psychological effect on people. Potentially, psychological injury may occur as well as physical injury and for some, this is more disabling than the fall itself. Such an impact is likely to affect their recovery rate, resulting in a longer hospital stay and greater healthcare costs.

This research program of study utilised a convergent mixed methods design and was conducted in two phases. Phase 1 employed a quantitative study using the Modified Falls Efficacy Scale (MFES) to measure a patient’s confidence upon admission to hospital, following a fall and prior to discharge. In Phase 2, a qualitative study used patient interviews interpreted by applying Van Manen’s (1990) approach to understand the patient’s experience of falling in hospital.

The Phase 1 results revealed a third of the patient sample was admitted to hospital as the result of a fall. Of these, 65% were categorised as medium falls risk. The mean admission MFES score was 5.5 out of 10 (ranging from 1 being not confident to 10 being completely confident), which increased to 6.1 on hospital discharge. Participants that sustained a fall post admission scored significantly lower admission MFES scores and their hospital length of stay was longer than those that did not fall. Furthermore, regardless of whether the participant was a faller or not, a significantly longer hospital stay was associated with an admission MFES score of less than

The findings from the qualitative study forming Phase 2 revealed three themes from the participant’s interviews: (i) Feeling safe; (ii) Realising the risk and (iii) Recovering independence and identity. These themes described a process wherein the participants moved through several stages before finally acknowledging their falls risk. Initially, their potential to fall again was not much of a concern: they trusted the staff to keep them safe and therefore tended not to seek assistance. Later, participants began to appreciate the reality of their falls risk but felt disempowered and disappointed with their loss of independence but were more receptive to help. Finally, as participants recovered, their desire to regain their prior independence became stronger; they wanted others to perceive them to be physically competent, not as a frail older person. However, this also meant that they were more willing to take risks concerning their mobility safety.

While Phase 1 confirmed that lack of confidence in participants’ ability to perform activities without falling was associated with hospital falls and increased length of stay, Phase 2 demonstrated how they transitioned from dependence to a desire to regain independence. Although ‘confidence’ was a term rarely used by participants in Phase 2, the three themes illustrate how participants’ behaviours progress from lack of confidence (feeling safe) to potential over-confidence (recovering independence and identity).

Phase 2 findings revealed how important it is to understand the patient’s perspective, specifically concerning their fall risk. For example, initially, when patients were feeling safe, they were dependent on them for care and support, and did not appear to fully appreciate their fall risk. At such times it is important for health professionals to counsel them about this risk, and to help them accept it. On the other hand, when this risk is realised (realising the risk) it is important to work closely with the patient to develop strategies to help mitigate risk, and to set realistic goals. Finally, as patients recover, and their desire to regain their prior independence becomes stronger, it is important for health professionals to work with patients to help modify risk-taking behaviours, and reinforce realistic goals.

Patients may experience a fear of falling prior to admission if they have previously experienced a fall therefore as part of a patient’s routine assessment on admission to hospital. All patients, whether the admission is as the result of a fall or not, should have their confidence level assessed as part of the routine assessment process. They can then be provided with ongoing support as required, with interventions including building confidence.

The perception of health care staff caring for patients who have experienced a fall was not researched in this study and is a recommendation for subsequent research.