General demographics and background information relevant to each patient are presented in the table overleaf. This is followed by tables detailing the attendees of the collaborative learning groups and the feedback sessions. These tables have been placed in the main text rather than as an appendix because the information acts as an introduction to the patients and staff who willingly agreed to participate in this study. Their “voices” are used extensively throughout the thesis in the form of verbatim quotations, yet these provide more than expressions of speech; they provide evidence of their experiences and stories. Therefore, the tables present an overview of who was recruited for this study:
Participant Pseudonym
Z/F - Zimmer frame. Falls Risk Factors include: History of Falls (<2), History of falls (3>), History of dizziness or blackouts, Mental State, Vision, Medications, Eliminations, Environmental Hazards, and Unsteadiness.
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Collaborative Learning Groups
Table 4.4b. Details of staff recruited from ward ‘A’
Ward ‘B’:
Table 4.4c. Details of staff recruited from ward ‘B’
NB: X = one participant
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Feedback sessions:
Ward ‘A’ Ward ‘B’
Physiotherapist Nurse Support worker
n = 1 n = 1 n = 1
Nurse Doctor Support worker
n = 3 n = 1 n = 2
TOTAL n = 3 TOTAL n = 6
Table 4.4d. Feedback session attendance details
4.5 Defining a fall
In order to explore the extent of the problem of patients falling in hospital it was essential to obtain an understanding of what participants believed constituted a fall. This was a good opportunity to compare the beliefs of patients to the professional understanding of the staff as well as to the descriptions contained within the literature (Zecevic et al., 2006). The ways in which patients perceived their fall, according to their own definition of it, would inevitably impact on their overall personal experience of the fall, including self-management and coping strategies, attitudes towards expecting or preventing a further fall, effects on rehabilitation, and recognition of their fall as being a “problem”.
4.5.1 The loss of balance
All patients defined their fall(s) by what has been established to be a major intrinsic risk factor i.e. poor balance. This could suggest that in a population of elderly fallers, there was a collective agreement as to what constituted a fall:
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David: “It’s some kind of weakness…weak legs.”
Margaret: “I think a fall is a lack of balance.”
Pat: “A trip is a kind of fall…tripping is falling.”
Joan: “A fall is when you’re unbalanced.”
Ron: “It’s a loss of balance…something to do with balance.”
This loss of balance was fundamental to their responses and was related to a ‘mechanical’
factor, such as tripping (participant Pat) or a lower limb weakness (participant David).
Patients were unable to expand upon their answer, even when prompted, which suggested their understanding of a falls definition was limited under the scrutiny of the research method. However, the remainder of the study demonstrated a more innate understanding of how each patient regarded their hospital fall(s) which grew beyond the limits of their initial responses. Therefore, the essence of their understanding did not appear to reside in direct questioning but rather within the depth of their overall experience. This highlighted the extent to which a fall penetrated into patients’ daily lives as well as illustrating the qualitative richness of data. Their responses, albeit brief, partly set the context for each patient’s participation in the study.
4.5.2 How staff defined a fall
The two definitions of a fall that were presented to staff were more comprehensive descriptions, commonly referenced in falls literature:
“A fall is an event which results in a person coming to rest inadvertently on the ground or other lower level, and other than as a consequence of the following:
sustaining a violent blow, loss of consciousness, sudden onset of paralysis, as in a stroke, an epileptic seizure.” (Kellogg International Working Group, 1987)
“[A fall is] an unexpected event in which the participant comes to rest on the ground, floor or lower level.” (Lamb et al., 2005)
These definitions provided a more structured understanding as to what precisely constituted a fall. Neither definition states that a fall is due to a loss of balance per se, but rather the occurrence of an event whereby an individual can come to an unexpected resting position.
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There was a collective agreement between staff that these definitions accurately described a fall:
Nurse 4: “I think both definitions are good together, although they are a bit too specific.”
Doctor 1: “I agree with the definitions, although there is a focus on a pathological reason for falling…this isn’t always the case as patients fall for different reasons.”
Nurse 1: “The definitions are reasonable…it often depends on the type of patient and professional understanding as to what they think a fall is.”
Nurse Practitioner 1: “There are different types of falls, such as cardiac…we have a falls and syncope service.”
Support Worker 3: “There are more near misses than true falls.”
It was important that qualified and non-qualified staff agreed on a mutual understanding of what constituted a fall if they were to be involved in the process of preventing patients from falling (Roe et al., 2008). The nursing and support staff had the main responsibility for completing the incident report forms following a fall on the wards. If these staff did not regard a patient as a “faller” due to a difference in their knowledge of what they considered to be a fall, then that patient’s fall might not have been reported or recorded (e.g. support worker 3’s comment: “there are more near misses than true falls”). Furthermore, the detail contained in the report forms might not have accurately described the incident, leading to insufficient information being gathered for organisational learning (NPSA, 2007).
4.5.3 The value of data and documentation
One of the secondary aims of the study was to examine the documentation which the ward used to report aspects of patients’ falls. The incident report forms were one of the principal ways of documenting falls, and so, as part of the study, staff reviewed past reports with the aim of identifying areas of positive management as well as highlighting issues which they could learn from in terms of developing their practice.
The immediate effects of under-reporting, under-recording and lack of detail in report forms were not so apparent, but the longer-term effects were important considering that the forms
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were part of a larger Trust process. For example, the incident reports could have been used by staff to highlight recurrent fallers and patients at risk of falling on their wards, thus identifying the need to allocate appropriate preventative measures:
Nurse 5: “The reports are a way of documenting falls and for staff to learn…as long as some action comes from the report, otherwise it can be a paper-exercise.”
Therapist 2: “Staff can learn from each incident, and the forms provide a means of gathering information such as where patients fell, if they suffered any injuries, what time of the day it was and so on.”
The incident forms presented an opportunity for organisational learning as the Trust’s health and safety department was responsible for gathering statistical data e.g. number of fallers, location of fall, time of fall, injuries sustained etc. This data was frequently discussed in quality care and patient safety meetings with NHS Trust managers who were placed in a position of implementing policies and procedures for more effective care and working conditions:
Therapist 1: “The incident report forms are discussed at the quality and safety meetings...so some end result usually happens.”
If they received information lacking in substance and accuracy, then inappropriate actions might have been taken. This would have resulted in hindered (misdirected) progress within the Trust, and financial resources being inappropriately spent (Oliver, 2007).