Becoming fall-safe: a framework for reducing inpatient falls

Background and literature review

The journey to reduce falls at BSUH began in April 2009. The catalyst for this work was, unfortunately, far from unique: a catastrophic fall leading to the death of a patient, a bereft family, guilt-ridden staff and damning media coverage. The Trust's Chief of Safety made a commitment to the family of the deceased patient to reduce the number of inpatient falls in the Trust, mindful of the fact that tackling the problem of inpatient falls is a huge challenge. The falls project team reviewed Cameron et al's (2010) Cochrane review of interventions for preventing falls, which concluded that there are no ‘quick fix’ interventions that, when implemented on their own, significantly reduce the rate of inpatient falls.

The timeline of the project is shown in Table 1.

Methodology: a traditional approach

In the first falls project in 2009, the falls project team applied a traditional change methodology, organising a Trust-wide launch of a falls programme, ensuring that every ward manager could attend. To emphasise the importance of this initiative, the team invited a national expert on falls to educate staff, a renowned speaker on leadership to inspire staff, a doctor passionate about reducing patient sedation as a strategy for reducing patient falls and physiotherapists and occupational therapists keen to work collaboratively with nurses.

At the launch, the ward managers and occupational therapists were given individualised reports detailing the number, rate, time, and other specific details of falls on their wards. Similar wards were grouped together in facilitated workshops to enable variations in performance to be compared and discussed. At the end of the workshop, each ward manager left with an individualised action plan, detailing how they were going to reduce the falls rate on their ward. Collectively, the ward managers identified 150 actions that they and their teams were going to take to reduce the number of falls in the Trust.

The initial results appeared promising, indicating a reduction in the monthly rate of falls. However, by the third month the rate of falls had fallen back into a pattern of normal variation. At the 3-month follow-up meeting, the wards reviewed their compliance with the action plans and generated new ones. This pattern continued for the rest of the year and, despite the considerable effort exerted into reducing the rate of falls, it remained stubbornly fixed, seemingly impermeable to change (see Figure 1). The review of performance in the first year divided opinion. Some ward managers genuinely believed progress was being made and pointed to the analogy of stars in the midnight sky: that the harder one looks, the more you will find, arguing that by focusing the ‘telescope’ on falls, more reporting was encouraged. Others suggested that the evidence base for falls reduction was weak, confirming their original contention that falls were inevitable. Another group suggested that the wrong actions had been chosen, or that staff were just not implementing them, or had not understood them.

With hindsight, the falls project team can now see that they followed a common approach to safety and quality initiatives when quality targets are not met. This was, namely, identifying best practice (guidelines, policies, care bundles, action plans etc) and monitoring performance to check this was done. If results failed to improve, more of the same was done; that is, more detailed guidelines were produced, there was more frequent scrutiny, and even more action plans. Although the team believed the latter can be necessary and useful, a point raised by one member made the team start to question this approach. They said:

This challenge provoked the project lead to start to question the underpinning theoretical assumptions behind this approach to quality improvement.

One of the observations during the course of this initiative was that much of the evidence base tells you ‘what to do’. The real challenge is making this ‘what you do’ to incorporate best practice into your daily activity.

By early 2010, it was clear that despite the project team's best efforts, this approach was not going to deliver a significant reduction in falls. Simultaneously, the team was beginning to consider alternative explanations for the results from the first year and developing a hunch that proved to be the key to unlocking the eventual approach to reducing the falls rate. This hunch went beyond locating responsibility for reducing falls primarily with ward leaders and was informed by insights from improvement methods inspired by complexity theory (Suchman, 2011).

The project team became interested in whether the behaviour of nurses on the ward could be influenced so that they were ‘falls aware’. The team also speculated that, if one individual member of staff behaved in a falls-aware manner, this behaviour might spread to other individuals who came into contact with this individual—in much the same way as a virus spreads through a group. Buchanan (2007) highlighted that we are, by our very nature, born imitators:

All too often it is these acts of imitation that bring our public bodies into disrepute; examples include the Panorama exposé of practices at the Winterbourne View care home in Bristol and the Mid Staffordshire NHS Foundation Trust public inquiry (Francis, 2013). When the degradation of patient care spreads through an institution, the team speculated that imitation appeared to be the vehicle. Believing imitation to be a powerful force, it was decided that, rather than taking the usual option of prescribing to staff what they should do through policies and guidelines, the team would focus on how individuals should act on a busy ward to reduce the likelihood of their patients falling.

Methodology: implementing an emergent design approach

As an alternative to the planned approach used in the first year, the project team adopted a model referred to as ‘emergent design’. The team abandoned the action plans and instead encouraged a mind-set of curiosity, flexibility and experimentation with the notion that ‘not knowing’ is a virtue, not a deficiency. Rather than planning many stages in advance, by using an emergent approach, the next step was only planned when the results of the previous were seen. This allowed opportunities to identify and utilise emergent patterns and ideas. The concept assumes there is no ‘silver bullet’; small changes are continuously introduced hoping that some will have a ripple effect and encourage other changes (Suchman, 2011). Another similar approach of ‘try a lot of things, keep what works’ has been found to be the basis for sustainable success in larger corporations (Collins and Porras, 1994).

A well-respected senior nurse was recruited to lead the project. Although she did not see herself as an expert in falls, staff recognised her as a leader with high professional standards, unafraid to challenge the status quo, and with an intellectual curiosity that sought to question and account for the rationale behind the professional actions of all involved in the delivery of patient care. Multifactorial complex problems such as falls have a tendency to be a challenge when applying the dominant approaches to quality improvement, such as care bundles, guidelines, educational programmes, action plans, etc. Instead, the project team acknowledged that no one individual, the project lead included, held all the answers to reducing the Trust's falls rate.

Utilising the Trust's online incident reporting system, the senior nurse augmented the incident investigation process to include an after action review (AAR) debrief following each reported fall. The AAR process facilitates reflection and feedback on individual, team and collective performance, in a non-confrontational fashion, with the spirit of an AAR being one of learning not blame. Schindler and Eppler (2003) suggested that creating an atmosphere that is conducive to encouraging openness and trust are crucial goals of the process to enable team learning, team building and team integrity.

An AAR is based around four overarching questions:

The process was designed to establish the extent of the deficit between the expectations of those involved and the facts surrounding each adverse event (Morrison and Meliza, 1999; Schindler and Eppler, 2003).

In practice, this meant that the senior nurse was alerted immediately, via email, to every fall as soon as it was reported via the Trust's online clinical incident reporting system, a well-established system that had been in use since 2007. This rapid notification fostered maximum opportunities for immediate learning via the AAR for everybody involved with the care of the patient who had fallen. The AAR framework provided a structure for talking about what was expected in relation to how to act in a way that minimised the chances of the patient falling again and future patients from falling. At the same time, the debriefs allowed the opportunity to review the difference between what was expected and what actually happened. The expectation–reality deficit was identified for each patient fall and the ward staff were given the opportunity to discuss and reflect on how events might have been prevented and how local systems or patterns of working could be improved. The emphasis was on constantly improving the learning about falls in each specific local context with the staff involved in caring for the patient that had fallen, thus empowering staff to affect change rather than portraying the process as punitive.

The focus was exclusively on the local context of the ward—its layout, patients, staffing and leadership were critical. The senior nurse was also mindful of generalising the results to a wider context. For example, when intentional toileting made a difference on one ward, the results were shared but not imposed on other wards. Thus through continuous AARs, wards learnt how to manage the risk of patients falling on their individual ward.

The AAR debriefs were with the staff directly involved in the care of the patient who had fallen (and when possible also the patient) and focused on exploration of their expectations of the outcome of their actions prior to the patient falling. In some cases, they had not anticipated the risk of a fall; in others, they had been forced to make pragmatic choices between other care priorities for patients, which had been judged to be of greater importance at the time. An important finding was that in these group reflections, the senior nurse moved beyond the more conventional use of the AAR tool as solely a technique for identifying a ‘root cause’ of the fall, to engaging in reflexive acts of imagination and exploration of future consequences and creative challenge to local constraints and habits such as ‘the way it is around here’ or ‘we've always done it like this.’

Learning was generated by working with frontline staff in developing safety solutions, which resulted in the continual updating of mutual expectations around nurses' behaviour in relation to falls-aware practice. Instead of being told what to do solely through policies and guidelines, it was contended that it is the staff delivering the care who hold the answers to improving the safety of care. At that time, the project team's belief was that behaviours spread through social groups by imitation, thus, if one nurse (particularly, an influential nurse) acts in a certain way, this increased the likelihood that others will follow this individual's behaviour through role modelling (Buchanan, 2007). As this approach has focused on behaviours (and behaviours are habitual), the team contended (as evidenced by the consistent falls rate in recent years) that because habits are hard to break, sustainability is built into the programme for the reasons explained below.

Staff were encouraged to develop practical ideas on how they would prevent the recurrence of falling. All ideas were embraced and tested through constant measurement of the wards' falls rates. Through countless iterations, the expectations around falls-aware practice evolved. An example of this would be:

This challenged the notion of ‘best practice’ as something fixed, towards it being understood as something that is continuously evolving and being re-tested in a local context. It also highlighted the idea that ‘best practice’ is not a simple rule to follow, devoid of the need for re-evaluation and consideration of the application of the rule locally. For example, this might mean weighing up the competing values such as ‘patient safety’ with others such as ‘maintaining dignity’ when choosing whether to remain present while the patient uses the toilet. If a familiar practice delivers an outcome that is unexpected or detrimental, it makes sense to re-evaluate whether or not it is still the right thing to do. If not, an alternative emerges through acts of group reflection in the AAR. If that worked, we found the revised practice becomes habituated because it then seemed the obvious thing to do. This is in line with the pragmatic tradition that underpins the team's approach (Stacey and Mowles, 2016).

The continued focus on expectations, and the evolution of these expectations in conjunction with the immediate discussion and re-examination of the project team's expectations of ‘falls-aware’ behaviour meant that learning from each specific fall was immediately translated into practice rather than through a written action plan to be enacted at a later date.

When talking about this work, the team is often asked for practical examples of what they do. The policy is that all patients are risk assessed on admission for any known risk factors that may precipitate a risk of falls. These include age, a history of falls, mobility, level of comprehension, any sensory impairment, medication, sleep patterns, neurological problems and continence. Other factors such as alcohol abuse, anticoagulant therapy, postural hypotension, recent surgery, sepsis or epidurals are also taken into account.

The assessment chart includes practical suggestions (see Table 2) for how staff can mitigate the risks of their patients falling, ranging from practical issues such as ensuring the bedside area is clutter-free, through to measures such as the need for increased supervision and observation, consideration of one-to-one specialing, (enhanced patient supervision by nursing staff) and the implementation of the Trust's multidisciplinary visual observation chart. Consideration is also given to the use of a low-level bed and the patient is assessed for suitability for a bed or chair alarm. In the event of a patient falling, an algorithm is followed for post-fall management and care. Each fall is reviewed to ensure that lessons are learnt, as outlined above. This may include further revision of both the risk assessment tool and the falls action care plan for that patient.

The focus was on exploring each fall and finding solutions within the existing resources. As the falls rates fell, the team asked staff what had made the most difference. One replied:

It was also noticeable that staff were beginning to behave differently, for example, asking if a patient was high risk before they were transferred into their ward and automatically putting them in a high-visibility area if they were. Or, accompanying the patient to the toilet and waiting for them rather than leaving them alone in the bathroom. These subtle shifts in behaviour and in how staff were talking about falls have, the authors argue, collectively made a big difference to the falls rate, as outlined in the results below.

Results

In the second year, as well as changing the theoretical approach to the project, the team also curtailed its ambition by focusing on one geographical block that housed eight elderly care and medical wards. This block was chosen as it accounted for almost a third of the falls in the Trust and the wards had some of the highest falls rates in the hospital. During the first year, these eight wards reported 484 falls at a rate of 9.1 falls per 1000 bed-stay days. In the second year, the rate of falls was reduced by 29% to 6.6 falls per 1000 bed stay days. As Table 3 illustrates, six of the eight wards reduced their falls rate during 2010-2011.

During 2011-2012, the BSUH project expanded to focus on reducing the rate of falls across an additional 31 acute inpatient wards, which between 2011 and 2019 accounted for 84% of the Trust's total number of falls. Areas excluded from the programme included intensive care, maternity and paediatrics as these areas had a relatively low rate of falls. Accident and emergency was also excluded as it does not have beds and therefore it was not possible to calculate a rate. Similarly, outpatient clinics, discharge lounges, dialysis units and day case areas were also excluded.

Table 4 and Figure 2 illustrate that the annual falls rate has continued to decline, with a rate of approximately 3.4 falls per 1000 bed days being sustained over the past 5 years (despite the absence of the senior nurse who left the Trust in 2016). By the end of the year 2018–2019, the overall reduction in falls was 46%, based on the rate in 2010–2011 of 6.23 falls per 1000 bed days. Based on costings from NHS Improvement, the 5108 fewer falls between 2011 and 2019 saved the Trust £13.3 million.

Limitations

It should be noted that between 2009 and 2018 the Trust opened new wards and closed some services. For the purpose of consistency, analysis in this article only contains data on those wards that remained unchanged. The project team was conscious that the measurement of the impact of this initiative was reliant on self-reported data (clinical incidents). Throughout the initiative the team constantly monitored the distribution of reported falls each day using the Poisson distribution. This approach allowed the team to calculate the probability of a certain number of reported falls on any particular day, while comparing this to the actual number of reported falls. Over the duration of this project course compliance or fit against the Poisson distribution curve rose from 86.8% in 2009–2010 to 94.2% for the wards involved in the second falls project. A finding that suggests the focus on falls did encourage a greater level of reporting.

Discussion

It was evident at the early stages of this initiative that there was a generalised attitude and belief that falls were largely unavoidable and therefore it was accepted that patients may fall while in hospital. The work by the project team and nursing staff over the past 10 years has reinforced the team's belief that understanding how such nursing behaviours and beliefs arise is the key to reducing patient falls. The initial hunch about the importance of imitation and positive role modelling in facilitating falls-safe behaviour and habits to spread through the Trust's ward-based teams was a helpful starting point, but a research grant and subsequent study enabled a more detailed understanding about the processes involved in changing professional values and norms regarding falls-safe practice (Norman et al, 2015).

The project team's findings built on and developed the initial assumption (informed by change and educational theories worked with over the years), that people learn through mimicking others more experienced or powerful than themselves, and that knowledge is something that is transferred from an expert to a novice, led to a different understanding of behaviour change, drawing on the pragmatic tradition (Mead, 1934). It became evident from the team's research that there was much more going on in the complex social interaction between the senior nurse and staff than ‘role modelling’ or simple mimicry.

By adopting the AAR framework in the way described, where reflexive conversation, rather than completion of the clinical incident investigation form (previously normally completed by the most senior staff for the sake of expediency, if at all), was the main focus, the project team recognised that the practising nurses and healthcare assistants often held the solution to many complex safety and quality problems. Thus the specialist expertise of the senior nurse involved the skilful facilitation of the debriefing, providing reflexive space in which she and others were able to have potentially difficult conversations about who had done what and why.

The project team recognised that such conversations had often been avoided, because it was felt that they may cause conflict and provoke strong emotions, especially if the patient has sustained a serious injury. Staff reported feeling guilty, ashamed, angry and blamed—both with themselves and with each other. They often found it hard to talk about such feelings, both because of fear of being blamed themselves, or of upsetting others by calling their professional judgement and practice into question. This is consistent with pragmatist John Dewey's definition of reflection as ‘the painful effort of disturbed habits to readjust themselves’ (Dewey, 1922; Brinkmann, 2013). Thus as our habits become problematic in each local context, we formulate conscious ideas that are tested through active action, ie in this way of thinking, thought is action, rather than something that precedes it, as assumed in the action-planning activities described earlier. The AAR debriefing provided the opportunity for the ward team to develop a shared understanding about possible causes for each fall, and renegotiate together whether their habitual practices (norms) for falls prevention were fit for purpose in their specific local environment. In this way of understanding, learning arises from their shared reflection about a specific incident, after which it no longer makes sense to follow previous habits of practice. This is because staff expectations about the possibilities of the outcomes of their actions/inaction are no longer the same, due to the insights gained from hearing other staff's perspectives about what happened when a patient fell, why they all did what they did, and the unforeseen consequences of their own actions and the actions of others. Although initially anxiety-provoking for all concerned, as the debriefings became the norm and valued by those participating, something seemed to shift, with staff coming to see themselves as having the potential to influence the emergent patterns of practice in their ward, both by their actions and omissions.

Subsequent research (Norman et al, 2015), helped the project team to recognise that what also shifted fundamentally was how staff were talking more frequently about preventing falls, and also how they were talking about this topic. As Shaw noted:

The project team concluded that the capacity of the ward teams to keep alive this narrative theme and its ongoing evolution may be one of the main reasons for sustaining the lower falls rate after the senior nurse leader left the project.

The subsequent wider conversations between wards in this growing community of practice identified generalised themes about what constituted falls-safe practice and these were then re-tested and adjusted once again in each specific ward situation. As one clinical manager noted in one of our focus groups when asked what had changed their mind:

The manager also said:

So rather than seeing ‘best practice’ as something located ‘in’ an expert who empowers others, or a policy or guideline, staff now see this as an ideal, a value, which is constantly tested in practice, which may require further investigation and need revising when this fails to deliver what was expected or they are surprised in some way. The project team also learnt that nurses' knowledge of falls prevention was seldom the problem in terms of falls awareness when assessing and documenting the risk of patients falling. This helped explain why approaches such as ensuring staff are aware of policies and guidelines while having some impact, on their own failed to yield the more radical improvements shown from year 2 onwards. The real challenge arose when staff had to make contextual judgements about falls-safe practice in complex situations, with competing priorities, in which every patient and each ward setting is slightly different and best practice is more nuanced than simply following the protocol, as in the above example, where beliefs about patients' dignity and privacy conflicted with those of safety when deciding whether or not to stay with a frail patient who was using the toilet.

Conclusion

Rather than now seeing falls solely as either a ‘systems’ problem (system failure), or one that locates the cause of the fall with individual staff (poor performance or lack of competency), as informed by the traditional improvement methods taught at the start of the project in 2009, the Trust's falls reduction programme drew on insights from complexity science and its helpful concept of emergence. In this way of thinking, a fall is understood as an event that emerges out of the micro-interactions between nurses and their patients, that is, because of what everyone is doing/not doing. From this perspective, relationships are fundamental and falls emerge from complex interactions, and not in isolation. This understanding emphasises the importance of the interactions between individuals, groups and their environment, since this determines the prevailing culture and the likelihood of a patient falling. Rather than solely training staff about techniques of falls prevention, as in the first year of this project, the senior nurse also worked with ward teams, supporting ward managers in facilitating post-fall debriefs. The project team concluded that it was during her conversations with staff about their expectations of their ‘fall-safe’ interventions in the light of each specific fall, that new insights emerged about fall-safe practice that were either accepted or rejected. In that sense, the team now see such reflexive conversations as ‘the work’ of the change. If staff come to see that a previously regarded intervention has the potential for harm, this is called to mind next time another intervention is required. Usually, it no longer makes sense to carry on doing what they did before, or, at the very least, they are able to imagine how they would give an account of their choice in the light of what they had learnt. As a result of the nonlinearity of these interactions, small changes can have large effects. The falls rate in the Trust has come down progressively since 2010.

By the project leads participating in and co-creating a habitual way of reflecting, together with those involved in situations in which patients have fallen, different conversations and practices emerged and the culture and the narrative in relation to falls has shifted away from seeing falls as an inevitable part of a patient's pathway to frailty. It is important to note that the authors are not suggesting that there is a ‘special’ way of communicating that individuals can learn. A central insight from this work (backed by the initial hunch of the project lead regarding how poor practice might spread) is that is in our ordinary everyday complex processes of relating—how we converse about who we are and what we think we are doing—cultural patterns of behaviour emerge. These are then judged retrospectively (and sometimes differently) by ourselves and others to be either ‘good’ or ‘bad’ practice. This work has emphasised that teamwork is a practice, often involving conflict, as values and expectations are contested and renegotiated. Keeping wider perspectives than our own in view may help offer a broader range of choice to staff facing complex situations where there may be conflicting safety demands that they have to prioritise.

The project team would argue that it is this process of habitual reflection that has led to the emergence of new behaviours. The fact that the behaviours tend to be habitual also explains the sustainability of the falls rate after the nursing lead left the Trust in 2016.

Our experience over the past 10 years has led the project team to conclude that a substantial number of inpatient falls are preventable. It is an old adage that ‘conversations are the mainstay of safety.’ This is why this approach emphasised the importance of paying careful attention to how people are talking about them. If these results were replicated across the NHS this would equate to 105 800 fewer falls per annum: a saving of £275 million. As one ward manager said: if we had invented a pill that halved the rate of falls in hospitals, why wouldn't we take it?

KEY POINTS

CPD reflective questions