Date of Degree
Winter 1-5-2024
Document Type
DNP Scholarly Project
Academic Department
School of Nursing
Degree Type
Doctoral
Degree Name
Doctor of Nursing Practice
Abstract
Problem:
Falls in hospital settings pose significant safety and financial risks, particularly in Behavioral Health Units (BHU), where fall rates often exceed national averages. Despite traditional fall prevention practices, such as risk assessments and post-fall huddles, the target BH unit continued to experience high fall rates, failing to meet the National Database of Nursing Quality Indicators (NDNQI) standards. The lack of alignment between fall prevention strategies and the unique needs of behavioral health patients contributed to these unmet targets.
Aim of the Project:
This project aimed to reduce the number of falls in a 41-bed BH unit by 20% over eight weeks through the implementation of an evidence-based bedside shift report (BSR) checklist. The intervention sought to improve communication, continuity of care, and patient engagement to reduce fall risks and promote patient safety.
Review of the Evidence:
Research indicates that fall prevention strategies, such as patient involvement, nurse-led interventions, and standardized risk assessments, effectively reduce fall rates. Evidence shows that bedside shift reports enhance communication between nursing staff and patients, improving fall prevention. Studies by Richardson et al. (2020) and Rohm et al. (2020) demonstrated significant fall reductions through multidisciplinary approaches, including patient engagement and staff education.
Project Design:
The project utilized the OhioHealth Change Model (OHCM) and the Plan, Do, Study, Act (PDSA) quality improvement framework. These models allowed for iterative testing and adjustments to ensure the effective implementation of the BSR intervention. Weekly evaluations were conducted to monitor compliance and refine processes based on staff feedback.
Intervention:
The intervention involved the introduction of an evidence-based BSR checklist for nursing staff during shift changes. Educational sessions were conducted for staff to ensure competency, and visual reminders were strategically placed to improve compliance with documentation during the bedside shift reports.
Significant Findings/Outcomes:
The project achieved a 66.6% reduction in the total number of falls, though the overall fall rate remained consistent. Compliance with BSRs reached 92%, demonstrating improved communication and patient safety.
Implications for Nursing:
This project underscores the importance of integrating evidence-based practices, such as bedside shift reports, into daily nursing routines. It highlights the need for ongoing education, patient engagement, and continuous quality improvement to enhance fall prevention and improve overall patient outcomes in behavioral health settings.
Recommended Citation
Moss, Kanesha, "Fall Prevention in Behavioral Health" (2024). Doctor of Nursing Practice (DNP) Scholarly Project. 14.
https://fuse.franklin.edu/dnp-project/14
Rights
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