Unintentional falls among inpatients are a major concern due to their frequency and the severity of their consequences. Research indicates that falls can be prevented through evidence-based nursing interventions. However, reductions in hospital fall rates have not occurred. While nursing care has tremendous impact on the outcomes of hospitalized veterans, relatively few VA initiatives have focused on the adoption of evidence-based nursing practices.
The primary objective was to examine the feasibility of using an existing nursing collaborative - the VA National Nursing Practice Network (NNPN) - to implement evidence-based falls prevention interventions in VA facilities. The specific aims were:
Aim 1: Identify staff nurses' perceived contextual barriers and/or facilitators to the implementation of an evidence-based falls prevention program.
Aim 2: Evaluate the effect of facilitated collaboration on the nurses' ability to overcome contextual barriers and leverage identified facilitators to successfully implement an evidence-based falls prevention program.
Aim 3: Evaluate nurses' perception of which elements of the collaboration and facilitation were helpful in implementing the falls prevention program.
Aim 4: Estimate the effect size of the falls prevention intervention program on fall rates and fall injury rates in the selected units.
This 12-month study used a participatory action research design to implement evidence-based falls prevention interventions on six units in three VA facilities. The facilitated collaboration model included: 1) monthly group phone conferences; 2) monthly site consultation calls; 3) monthly webinar sessions to review pertinent falls prevention guidelines and implementation strategies; and 4) an on-site visit by the project facilitation team.
Project data included formative field notes collected during the course of the intervention, two summative focus groups, one in depth interview, and monthly rates of falls and fall-related injuries on participating units. Qualitative data was analyzed for thematic content, including a modified coding scheme developed by the research team based on a priori research hypotheses and emergent, inductive themes.
Analyses have been completed comparing mean monthly fall rates during a six-month period prior to start of the study (February-July 2010) and during a six-month period after the initiation of the collaborative intervention (February-July 2011). Mean fall rates per 1000 bed days in 2010, compared to 2011, found moderate declines in 3 of the 6 hospital units (A, B, and E). Mean monthly fall rates were:
Site 1: Unit A, 6.5 vs. 2.6 falls / 1000 bed days; Unit B, 6.8 vs. 2.8 falls / 1000 bed days.
Site 2: Unit C, 3.2 vs. 2.4 falls / 1000 bed days; Unit D, 4.2 vs. 4.1 falls / 1000 bed days.
Site 3: Unit E, 10.3 vs. 6.4 falls / 1000 bed days, Unit F, 8.5 vs. 9.6 falls / 1000 bed days.
Analyses of qualitative data identified a number of barriers to implementing best practices (including turnover of staff, competing changes, lack of protected time for staff nurses to participate in collaborative activities, lack of senior leadership, and lack of strong champion), as well as a number of facilitating factors (strong supportive senior leadership, efficient data collection and reporting systems, access to research articles, strong change champion, and early site visits by study facilitator). All sites confirmed that collaborating across sites was beneficial in sharing tools, providing support, providing a "safe" environment for discussion and brainstorming, and preventing "fall fatigue". In addition, participants were able to identify barriers that were overcome by expert facilitation and collaboration with other sites. There was a strong reoccurring theme of the importance of connecting with others who are encountering similar barriers to problem solve and refocus. Internal champions across sites indentified their own inexperience as an initial barrier, but articulated the lessons learned from the experience and how they would "do things differently next time."
Recommendations for improvement of future collaborations include: 1) recording of the monthly phone calls with continuous access on Sharepoint to increase participation by front line staff nurses; 2) more direct feedback and recommendations to the staff by the facilitator (e.g., not relying on local administrative staff to relay the input); 3) on-going site specific summaries of accomplishments and progress; 4) more face to face meetings if funding permits; 5) disseminate the value of the collaborative through conference presentations; and 6) increase the number of collaboratives available on different clinical topics.
Analysis of field notes support that changes in fall rates were closely related to level of participation in the collaborative, as well as leadership support at the site.
The project provides important insights on the effectiveness of a nursing collaborative model to impact nurse sensitive indicators and ultimately patient outcomes. Findings from the study support previous research on the benefits of nurses engaging in action based learning with their peers. Using central facilitation, group calls and webinars, access to research articles, and sharing of tools and resources across sites provides an innovative way to maximize resources to implement change. In addition, participants were able to make several recommendations to improve the collaborative process. The project addressed a known gap in care and built nursing capacity for implementing other evidence-based practices for inpatient care.
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- Cullen L, Adams S. An evidence-based practice model. Journal of Perianesthesia Nursing : Official Journal of The American Society of Perianesthesia Nurses / American Society of Perianesthesia Nurses. 2010 Oct 1; 25(5):307-10.
- Adams SL. Implementation Series: Keeping the Project in the Forefront. [Cyberseminar]. 2010 Nov 9.
- Adams SL. Reducing Falls and Fall-related Injuries in Hospitalized Veterans. Poster session presented at: Midwest Nursing Research Society Annual Conference; 2012 Apr 13; Dearborn, MI.
- Adams SL. Examining Nurse Manager Behaviors Related to Use of Evidence-Based Practices on Nursing Units. Poster session presented at: Knowledge Utilization Annual Colloquium; 2011 Jun 15; Belfast, Ireland.
- Adams SL, Sullivan S, Freundl M. Implementation Research for Reducing Falls in Hospitalized Veterans. Paper presented at: Evidence-Based Practice Center National Conference; 2011 Apr 28; Iowa City, IA.