Hospital falls prevention with patient education: a scoping review

Falls in hospitals remain an ongoing concern, despite world-wide recognition of this persistent problem [1]. Rates vary widely across hospitals globally and typically range from 3 to 11 falls per 1000 bed days [2‐4]. Around 25% of hospital falls are injurious, and result in fractures, soft-tissue injuries and fear of falling [5‐7]. As reported in the National Institute for Health and Care Excellence (NICE) guidelines [8], hospitalised older adults are at risk of falling due to factors such as ill health, co-morbidities, anaesthetics, pain, medications, polypharmacy and muscle weakness, yet many patients do not realise their risk [9‐12]. Patient education is one strategy to address this gap by increasing engagement in falls prevention programs [6, 13]. Alongside clinician education, medication management, multi-disciplinary reviews, environmental modifications, assistive devices, and hospital systems and policies, education assists patients to self-manage their own falls risk [6, 14‐17].

Patient education is important because there can be a mismatch between perceived and actual falls risk whilst in hospital [10‐12]. Hospital falls risks have been historically assessed using tools such as the Falls Risk Assessment Tool (FRAT) [18], St Thomas’s Risk Assessment Tool (STRATIFY) [19] and the Hendrich II Fall Risk Model [20]. Some of these assign a falls risk score to each patient [18‐20]. Clinicians can also use their clinical judgement and application of research evidence on a case-to-case basis to determine falls risk. Carefully considered, evidence-based decision making can assist the selection of individualised falls prevention interventions [21]. Unfortunately, some patients appear to engage in risk taking behaviours that increase their falls risk [22] such as not pressing the call bell when needing to walk to the toilet [23], or not waiting for nurses to arrive before attempting to mobilise, when they are unsafe to walk without supervision [12]. Particularly for people with poor balance, cognitive impairment or gait disorders, there is an increased falls risk whilst in hospital [12]. Up to 80% of falls occur when patients are not observed [24]. Some patients initiate risky decisions about mobility based on their own judgements, without always seeking help from nurses or other health professionals [25]. Others report feeling secure by virtue of being in a hospital environment, even though they are actually at high risk of falling [11, 22, 26]. Although risk taking is not always problematic, it becomes dangerous when excessive, poorly considered or not in a supported environment [22].

Patient education aims to increase a person’s awareness of their own falls risk and to provide them with strategies to mitigate falls whilst hospitalised [27]. There are varying levels of evidence for different methods of patient falls prevention education, such as handouts [28, 29], videotapes [30, 31], posters [32, 33], falls risk communication alerts and assistive devices (such as sensors, wristbands and bed alarms) [33, 34], and face-to-face discussions about safe footwear and other interventions [35, 36]. Whilst education is an aspect of most hospital falls prevention programs, few studies have evaluated the outcomes or design of educational components, based on educational theory [14]. A systematic review by Lee et al. [37] reported preliminary evidence for the benefits of delivering hospital patient education informed by educational theory and the principles of health behaviour change. Recent investigations add further weight to the idea that falls mitigation interventions that incorporate evidence-based design are successful at reducing falls [38‐42].

For these reasons, we conducted a scoping review to identify gaps in current research by summarising and evaluating different sources of evidence from systematic reviews, narrative literature reviews, clinical trials and grey literature [41, 42]. Given the potential for patient education to mitigate hospital falls, this scoping review aimed to (i) conduct an up to date search of hospital falls prevention interventions pertaining to patient education; (ii) appraise the design of hospital patient education programs and; (iii) identify and critique variables, tools and measures used to quantify changes in falls and associated outcomes.

This scoping review showed patient education to be an important part of falls prevention in hospitals, whether given as a single intervention or delivered within a multifactorial fall mitigation context. Several knowledge gaps were identified. Most notably, many of the identified studies had a minimal focus on educational design and the quality of education. Many were not designed according to evidence-based educational principles or learning theories. Few engaged patients in active learning, which is argued to be associated with gaining a deeper level of understanding and higher engagement [81].

Some links were found between the quality of education programs and a reduction in falls and fall-related injuries. Twenty-eight trials assessed falls-related outcomes and eight of these were RCTs with level II evidence [82], three of which scored moderate for patient education quality [30, 38, 56]. Of these, Hill et al. [38] achieved a significant reduction in falls post-education. However, Haines et al. [30] and Kiyoshi-Teo et al. [56] did not find a difference in falls rates and monthly incidence rates following patient education. Hill et al. [38] reported teacher characteristics and provided age-appropriate learning activities for patients as well as specific falls education content. The trial design used by Hill et al. [38] also appeared to facilitate a growing safety culture in the ward and was developed specifically for hospital inpatients. The content focused on encouraging patients to interact with staff who could have provided reinforcement for the learning that occurred. The use of videotapes delivered on screens and with headphones aimed to assist patients with visual and auditory impairments. This may have increased the uptake of falls prevention strategies as falls rates were reduced across whole units. These units included patients with impaired cognition who did not receive personalised falls education.

The finding that patient education reduces hospital falls was also evident in many of the non-RCT studies [82]. Those which scored high on the quality metric appeared to be more effective in reducing falls-related outcomes, regardless of whether the intervention was single or multifactorial. For example, Martin [61] trialled patient education as a single intervention. They utilised a validated model of the “teach-back” method [83] and found that falls were reduced post-intervention. The trial by Quigley et al. [73] conducted falls education using “teach-back” which was part of a multifactorial intervention and was reported to reduce hospital falls rates.

For the remaining studies, there was a trend towards multifactorial interventions with a component of targeted patient education being most helpful. Five of these were RCTs, and three of them reported a statistically significant reduction in hospital falls rates with multifactorial interventions [32, 34, 57]. This trend was also reflected in non-RCT studies, most of which trialled patient education as part of a multifactorial bundle (Additional file 7). These data need to be interpreted cautiously due to the heterogeneity in education modes, environments and hospital types. It is difficult to ascertain the influence of the patient education component alone within multifactorial interventions.

Few trials applied educational theory, educational principles or a patient engagement framework to inform the design of patient education programs. Incorporating these factors has been shown to optimise health education in other chronic diseases, such as heart failure [84, 85] and cancer [86, 87]. Engaging participants in active learning can also be advantageous [81]. By actively participating in the learning process, patients are more likely to improve their self-efficacy and level of knowledge about falls prevention [88]. Adults are intrinsically motivated to learn, and education can improve their self-perceived falls risk and promote positive changes in health behaviours [89, 90]. Applying health behaviour change models with adequate descriptions is therefore recommended when designing and implementing hospital falls prevention programs [91‐93].

The literature that we reviewed suggested that patients can sometimes experience feelings of stress or loss of control during their hospitalisation [94, 95]. This has the potential to affect their ability to process and retain new information [94, 95], such as how to prevent falls in different contexts. When designing new falls prevention programs for hospital patients, it seems important to consider the context, task demands and individual needs.

A recurring theme in the literature that we reviewed was that cognitive impairment can have an adverse effect on the ability of patients to prevent falls [30, 38]. The design and modification of patient education programs for people with cognitive impairment needs careful consideration. A study by Kiegaldie et al. [96] illustrated the challenges associated with delivering education to people with cognitive impairment. They recommended the use of specific techniques such as “chunking”, repetition, simplification, rephrasing, using concrete examples/stories and frequent positive reinforcement when designing education programmes for patients with cognitive impairment [46, 96]. The overall message is that more research is needed on how to modify existing falls education programmes to these patients and how best to measure educational outcomes when cognition is impaired.

There were some limitations of this review, such as not including articles that were published in languages other than English and the exclusion of paediatric and non-hospital populations. Not all trials gave falls rates, and some only conducted pre-post analyses on falls-related outcomes. We found numerous falls prevention strategies for use in hospitals yet many had low levels of supporting evidence [14]. In a recent Cochrane systematic review, Cameron et al. [14] reported the quality of most studies on hospital falls prevention to be low. Although that review concluded that some multifactorial interventions and some single methods may reduce falls rates in hospitals, further high quality controlled clinical trials are needed to verify whether this is always the case. Few investigations explored whether physically restricting mobility could reduce hospital falls, possibly due to ethics concerns pertaining to physical restraints. A strength of this review was the scoping methodology [42‐44] which allowed a broad examination of the literature to identify and clarify key concepts in hospital falls prevention education [41, 43].

Evidence is accumulating that hospital falls prevention interventions that include patient education have the potential to reduce falls. Although no single model of patient education was found to be effective for every person, this scoping review identified key themes. These were: (i) the design and delivery of falls education needs to take into account individual falls risks and environmental context [38]; (ii) a combination of education modes (e.g. face to face discussions, handouts, videotapes) can sometimes be more effective than using a single modality, although this varies according to hospital settings and patient characteristics; (iii) falls education interventions are most helpful when their design incorporates theories of health behaviour change and educational principles; (iv) incorporation of an active learning design can better engage some patients. In addition, reporting of interventions should follow established guidelines to ensure transparency and improve the quality of hospital falls research [8, 97].