1.
Introduction
A fall is defined as an event that results in a person coming to rest inadvertently on the ground or floor or other lower level [1]. Falls and their consequences are major public health problems, making them the second leading cause of accidental deaths worldwide [2]. Fall is reported as the most frequent patient safety event occurring in hospitals [3]. Falls occur at a rate of 3–5 per 1000 occupied bed days, and the Agency for Healthcare Research and Quality estimates that each year 700000 to 1 million hospitalized patients fall [4]. Nearly one in every three inpatients aged 65 years and older sustains a fall. The traumatic complications of falls include physical injury, functional impairment, increased rate of hospitalization, and delayed recovery as a result people suffer a lot with a huge burden to the family, health sector, and economy of the country [5]–[7]. A significant proportion of non-traumatic falls, often instill fear of fall- a post-fall syndrome which includes dependency, loss of autonomy, confusion, immobilization, and depression, which will lead to a further restriction in daily activities and thus affects Quality of life [8],[9]. Despite the continued efforts to decrease falls in hospital settings, there continues to be an increased incidence of inpatient falls. Nurses are the true backbone of any health facility. They provide constant care to patients and they must be properly trained to identify risk factors and employ strategies to prevent them. Due to demanding work schedules, lack of awareness, and complex patient profiles, there are high chances that preventable aspects of these “geriatric giants” are not well addressed and often overlooked. The disabilities of the older adults in mental, physical, and social domains are sometimes misperceived as an unavoidable concern of older age people, it has to be improved. Conditions such as incontinence, intellectual impairment, instability, and immobility are common in older adults and have a greater impact on quality of life [10]. The comprehensive geriatric assessment (CGA) process is a multidisciplinary diagnostic and treatment option that recognizes the medical, functional, and psychosocial limitations of frail older adults to create a strategy to increase the health conditions with aging [11]. CGA needs evaluation in physical, affective, social, cognitive, financial, environmental conditions, and spiritual conditions which have aid in older age people health. CGA is completely based on the systematic evaluation by healthcare professionals to find health problems and gain better health outcomes. The assessment team carries out different components of the process, mostly physicians, nurses, physician assistants, and physiotherapists conduct the assessment of older adults. The 24-hour practicing nurses are expected to play a major role in the caring process of older adults as well as in the assessment practice. Prolonged care and assessment of the individuals help the nurses to give complete care. Such things are possible only by the comprehensive assessment process. To ensure the kills of the nurses, a current study was conducted on the knowledge and attitude of nurses attribute to disseminating and establishing a foundation for fall preventive activities in Tertiary care hospitals. Even though falls among hospitalized patient is a well-recognized topic in both nursing and medical literature, in many developing countries it has not been prioritized for research. Hence, the current study had been devised to find out these lacunae and establish the best care for the patients.
2.
Materials and methods
2.1. Study design and participants
This cross-sectional study was conducted in Panimalar Medical College Hospital & Research Institute, Chennai, Tamil Nadu, India. A probability random sampling technique was used for selecting the study participants. The researcher's recruited 339 registered nurses who are working in tertiary care hospitals across Chennai aged over 20 years. This study was conducted between February, 2020 to May, 2020. Registered nurses who can read and write English and those willing to give informed consent were only included in the study. Nursing students, trainees, and who were not available during data collection were excluded from participating in the study. A semi-structured questionnaire was used to gather information from concerned participants at a single point in time. Confidentiality of all participants was maintained by assigning a unique respondent ID to each participant. This study protocol was approved by the Institutional Review Board (IRB) of the Panimalar Medical College Hospital & Research Institute, Chennai (Panimalar Medical College Hospital & Research Institute IRB #1/2020/003) and conformed to the requirements of the Declaration of Helsinki (as revised in Seoul 2008). Informed consent has been obtained from all the participants of the study.
2.2. Measures
A modified version of the previously validated standard questionnaire was administered by the investigators comprised of 52 questions/statements on demographic characteristics and information about the fall and its risk factors [12]. The demographics were followed by 3 sections with a set of questions/statements. Section-1 incorporated 16 simple questions, to assess the knowledge of falls by selecting correct and incorrect options. Section-2 embraced 13 positive and negative statements on 5 points Likert scale, the respondents have to record their responses on the 5 points Likert scale ranging from: Strongly agree (SA), Agree (A), Unsure (U), Disagree (D), Strongly Disagree (SD) for obtaining information on the attitude of fall and section-3 encompassed risk factor category question with the list of 16 risk factors where the respondent has to select related /unrelated option. The reliability of this tool was analyzed using Cronbach's alpha, wherein α = 0.75.
2.3. Sample size estimation
The sample size (n) has been arrived at 313, based on the hypothesis testing for single proportion with 2 sided with the population proportion of 0.82, sample proportion of 0.757, power (%) of 80, and alpha error (%) of 5.
2.4. Statistical analysis
Each statement/question was numerically coded to obtain a score for knowledge and attitude of falls and awareness of fall risk factors. All the categorical variables are presented as numbers and percentages. Descriptive analysis was performed using univariate statistics to report the Mean and Standard Deviation (SD) for the continuous variable and frequency distributions for the categorical variables. Correlation, non-parametric tests of Kruskal-Wallis and Mann-Whitney test were performed to compare differences in the variables. All reported statistically significant differences were calculated at the 95% confidence level. Spearman's rho test measured the strength and direction of the relationship between two variables. The Chi-square test was used to assess the association between categorical variables. Statistical significance was set at P < 0.05. All statistical analyses were performed using Statistical Package for Social Science (SPSS, version 17) for Microsoft Windows, SPSS Inc. USA.
3.
Results
Of the 439 participants who were intended to receive survey questionnaires, 339 participants submitted completed questionnaires: a response rate of 75% leaving 339 valid for analysis. Table 1 depicted the demographic characteristics of the nurses. Out of the participants (n = 339) are Female (84.1%) and Male (15.9%). Most of the nurses participated in the study (36.3%) where their professional experience is less than 6 months. 21% of the respondent have experienced patients' that have sustained falls whereas (56.3%) have not experienced previous patient fall. The majority of the respondent (71.7%) have received fall prevention education. However, only (18.3%) were extremely familiar with fall prevention activities (Table 2).
3.1. Knowledge on fall
Considering the overall level of knowledge of the 339 participants, 26.8% (n = 91) of individuals had inadequate knowledge, 57.5% (n = 193) had moderately adequate knowledge, and 15.6% (n = 53) had adequate knowledge of falls (Figure 1). The average mean knowledge of the study participants was 10.05 ± 2.21 (Table 3). Correlation between level of knowledge and participants' years of experience in nursing alone showed a statistically significant relationship at P = 0.01 among all the selected demographic variables. (Table 4) Similarly, only years of experience in nursing have a statistically significant association (P = 0.01) with the level of knowledge on falls (Table 5).
The statements concerned with diseases condition and medications related to falls as expressed by the participants represented the lowest of all knowledge scores were: 42% for “Taking medicine for diabetics is not related to falling” and “Intravenous therapy or intravenous access has a risk for fall”. 46% for “Depression is not related to falling and 47.2% for “Taking medicines for blood pressure is not related to falling” (Table 6).
3.2. Attitude towards fall
In this present study, 2% (n = 6) had unfavorable attitude, 42.2% (n = 143) had moderately favorable attitude and 57.2% had favorable attitude towards fall (Figure 1). 49.69 ± 5.746 was the average mean attitude of the study participants (Table 5). The participants' attitudes towards falls had a statistically significant relationship at P = 0.001 with age, education, and experience in nursing and previous fall experience at P = 0.05 (Table 6). There were statistically significant associations between an attitude toward falls with age (0.05), gender (P = 0.001), educational qualification (P < 0.001), and experience in nursing (P = 0.001) (Table 5).
The lowest mean score for the statements on an attitude of fall was: 2.58 ± 1.24 for the statement “hospital environment is safe for fall”. 2.66 ± 1.26 for “fall is unavoidable”. Majority of the participants expressed their favorable attitude toward the need for fall preventive education (Table 7).
3.3. Awareness of fall risk factors
The participants level of awareness on fall risk factors were 38.3% (n = 130) adequate, 52.2% (n = 177) moderately adequate and 9.4% (n = 32) inadequate (Figure 1). The average mean value was 11.48 ± 2.165 (Table 3). The correlation between fall knowledge, an attitude toward fall, and awareness of fall risk factors were highly significant at P = 0.0001 with 95% CI (Table 3).
4.
Discussion
Fall in hospitalized patients is almost always preventable [13],[14]. Nurses with adequate knowledge and awareness of falls and their risk factors are anticipated to bring about be a significant reduction in the prevalence of fall occurrence and a positive influence on falls among hospitalized patients [15]. In our present study, 43.7% of nurses had previous patient fall experience which is similar to that reported by various studies [16],[17]. This is much higher than that reported by Kim et al. [18]. These differences may be due to the nature of hospital infrastructure, years of nursing training programs, and differences in patient profiles.
Even though the majority of the participants (71.7%) reported “received fall prevention education”, only 15.6% had an adequate level of knowledge which was lower when compared with the study reported by Kim et al. [18], where 85.7% of nurses had a high level of knowledge. Similar to our study, Laing et al. [19] reported a lower level of knowledge among health workers about falls. In our study majority of the nurses had working experience of fewer than 2 years hence low level of knowledge regarding a complex multifactorial event like a fall can be attributed.
In the assessment of knowledge session of the questionnaire statements about diseases condition, treatment-related, and medications related to falls as expressed by the participants represented the lowest of all scores similar to previous studies [18],[19]. This could be attributed to not incorporating multidisciplinary evidenced-based training on falls with a new perspective. In India, it is a harsh reality that many hospitals neither have standard policies and procedures nor training programs on falls and their prevention. Laing et al. [19] revealed that the knowledge and skills of nurses related to falls and their prevention were improved after the training confirming the need for evidence-based training. Hence, the introduction of a care bundle approach frequent in-services and focus groups may enhance nurses learning and improve clinical outcomes.
This study revealed majority 57.2% had a favorable attitude towards falls which supports the study by Kim CG et al. [17] where the attitude level of nurses was 77.2% positive toward falls. This may be due to the social and cultural empathy incorporated in training. Contradictory results have been shown in various other studies [16],[17],[20]. This may be due to the difference in nature of study participants (students, workers). However, the potential gaps in awareness of fall risk factors may be addressed by developing nurse-sensitive, context-specific fall-prevention clinical guidelines for practice in India.
In our study, 52.2% had moderately adequate awareness of fall risk factors. In contrast, 60% of health care professionals including nurses had little or some awareness of fall risk factors in a study [21],[22]. Therefore, an onsite training program on awareness of fall risk factors designed for nurses is crucial and need of the hour to help them identify the most important risk factors for falls and translate the knowledge into practice. The majority of the participants (66.1%) expressed a need for fall preventive education in this study this was achieved through developing a multifactorial, multidisciplinary fall preventive educational program and introducing a bundle approach to falls.
The years of experience in nursing showed both a strong association and a positive relationship with the level of knowledge. This implies that the knowledge improves as they gain more working experience because they obtain more information and hands-on experience. The attitude of nurses towards falls had strong associations with age, gender, educational qualification, and experience in nursing. This implies that as their experience in nursing care increases with education and patient care the more positive attitude they develop toward falls and their preventive measure.
Interestingly, our study also showed a strong correlation between knowledge, attitude, and awareness of fall preventive measures with each other. This is supported by several studies as well [17]–[19],[23]. This shows that continued medical education and training of nurses are required to bring about an overall change in fall incidents in hospitalized patients.
5.
Limitations
This study was conducted with certain limitations. The study participants were selected based on the probability random sampling technique. Registered nurses who are able to read and write English and those willing to give informed consent were only included in the study.
6.
Conclusions
In our study, it is evident that there is a void that has to be filled to improve the knowledge, attitude, and awareness of falls and their risk factors. There is a need for extensive education and holistic, multi factorial, and interdisciplinary training program to be undertaken through various health care organizations including governmental and non-governmental organizations regarding falls and risk factors of falls to reduce fall occurrence thereby ensuring patient safety.
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