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Discusses the management of risk in the care of older adults in hospitals

| December 23, 2012

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This essay critically discusses the management of risk in the care of older adults in hospitals, in the prevention of falls.The rationale for selecting this topic is based on several factors.  According to Nazarko (2008), elderly people are admitted to hospital for a variety of health conditions. The family of the patient trust that they are being cared for in a safe environment. However, every environment carries a physical risk to the people within it and this essay will focus on the fact that older people admitted to hospital are more susceptible to experiencing falls (Nazarko, 2008). Moreover, the National Patient Safety agency (NPSA) (2007) state that there are more than two hundred thousand falls that occur in NHS hospitals in England and Wales. NHS Greater Glasgow and Clyde (2011) state that one of the biggest admission for hospital in elderly people are falls. Out of that figure, 99% of them are unhurt, minor or moderate injuries, however 1% of those falls cause severe injury, death or fracture bones. Falls are a major problem in hospitals as well as outside of hospital in the UK. Various studies have shown that 30-50% of the population are over 65years old. Most of those falls are happening in the nursing home setting and 10-20 % cause severe injuries (Kennedy 2010, Pountney 2009a and Weaver 2008).

Adding to this rationale, Pereault and Bourbonnaise (2005) state that the nurse’s role is to take care of patients from the first time s/he enters the door of the healthcare environment, through assessments, appointments, surgery or any other treatment, as well as discharge of patients from hospitals. Therefore a focus on falls prevention is essential.

For this reason author has chosen to focus on this topic. It defines risk and then identifies and explains the nurse’s role in risk assessment and management of elderly people in the hospital and nursing home settings. The essay will highlight why people experience falls, the different the contributing factors that can affect their balance whilst in a professional care setting.  The risks are and how risk management can be used to prevent older people who are in hospital falling as a result of residing within this environment are critically discussed. To do so key measures in place that aim to minimise risk and maximise patient safety in the clinical environment are therefore evaluated. One of the methods this essay will examine is the five HSE steps of how to manage risk in the working environment in practice. There will be an in depth analysis of two different case studies of the STRATIFY risk assessment tool, to show the weaknesses and strengths of this tool. The essay will explore the difference education and training can have on the quality of care.

The Health and Safety Executive (HSE 2006) state that every day in our life we come across risks. It may be in or outside our homes, as well as in the working environment. Kennedy (2008) states that risk can be described as an episode where something valuable or someone can be affected or damaged and where there is uncertainty of the outcome. Leyshon (2005) have stated that before any action to manage it, risk must be identified in the first place. To improve the health and safety environment in the work place assessing, measuring and controlling risk is therefore essential.

The Department of Health (2006) state that ten percent of patients admitted to hospital will be negatively impacted as a result of an avoidable error separate to the original reason that they were admitted. They also state that risks could be reduced by as much as 50%if lessons from previous risk incidents were recorded and analysed. This would therefore serve to reduce the possibility of the same mistake recurring. Tingle (2006) provides further support to this by adding that if lessons were learned from previous incidents it would also help to save costs to the NHS. According to Mitchell (2009), falls can cost the NHS upwards of 1.7 billion pounds a year. Therefore, nurses can have a significant impact on this by promoting patient safety in the NHS to improve care for patients and protect them from any harm, whilst saving money. According to the Nursing and Midwifery Council (NMC) (2008) code of conduct the nurse is responsible for taking care and treating patients with dignity and respect whilst reducing the risk of further harm.

Leyshon (2005) suggested that the areas to be focused on in an effort to reduce risks and to protect patients from harm are to assess the work environment and appropriately manage the known risks, as well as being aware of, and minimising, other probable risks. The goal to minimise risk in the healthcare setting means that nurses and other healthcare professionals should critically evaluate past events that have had a negative effect on practice and there should be focus on vulnerabilities and how risks can be managed.

Mills and Bowker (2007) further state that there are many ways to assess risk in the health care environment. However, they highlight a simple understanding of the risk assessment tools can help staff develop better understanding of the advantages of successful risk assessment. The Health and Safety Executive (HSE) (2006) identify five easy steps to assess risk in any work place environment which has also been successfully put into practice. The first step is to identify the risk, recognize strengths and weakness to reduce risk and reach the aim using a method, such as a risk check list. Nazarko (2005) also agrees that risk needs to be identified in the first place and then we can take care of those who are at risk to minimize risk. The HSE (2003) states that, the second step is to assess who may be harmed and how using appropriate risk management tools, such as a scoring system, which are individual for different risk assessments. The third step is to evaluate the risk.  According to Young and Woodock (2011) an important question is whether the hazard can be eliminated altogether by removing it.  If this is not possible it must be controlled so as to reduce the chance of harm.

According to Waterhouse (2007) the fourth step of HSE risk management is the recording method. The most important part of this method is identified as keeping a record of the patient’s risk assessment. This way, safety is improved and it is shared amongst colleagues as essential practice to protect patients from harm. This also applies to the NMC code of conduct (2008) as good practice, such that information must be shared with colleagues to maintain the safety of those for whom nurses are taking care. The last step of risk assessment is the review which must occur on a daily and ongoing basis to protect patients from hazards. This is constantly monitored to determine progress and changes to their condition. There may be some improvement or adversely, there may be some changes with patient’s health and risk assessments. Therefore it is vital that they must always be accurately recorded and kept up to date. Fullbrook (2007) agreed with these studies, adding that from the nurse’s point of view, assessment is the most important part of risk management. Nurses assess all of the issues that can have an impact on clinical practice and the nurse will often be the first to identify potential difficulties in their working environment, as they are there on a daily basis.

According to Hughes and Marshall (2009) risk can be separated into three categories: long-term, medium term and short term. Dependant on the risk classification, the implementation of measures to mitigate the risk vary, according to the size and complexity of the task. These issues in risk are particularly relevant to management of falls in healthcare environments.


A study by Pountney (2009b) shows that falls mostly occur in either the morning or evening time due to medication such as night sedation, make them unsteady, visiting the toilet – incontinence first thing in the morning as well as inappropriate shoes making elderly people’s mobility unsteady. Therefore as a result of this, nurses and other healthcare staff must spend more time with those patients, at these times, to protect them from harm.


Nazarko (2007) stated that people in hospital who are inpatients are individuals and all of them have a different reason for being in care.  As they are unwell and are often extremely weak they may be at risk of falls. There are many factors that can affect body balance and cause falls, such as age, disease or medication. Some of them may have some obstacles to stop them being fully mobilized like catheter in-situ, drip stand, and as a result of their injuries they may be confused which makes it even harder for them to be mobile with those obstacles. Therefore it is important for nurses and other staff  to have better contact with those patients to provide the best possible care of patients be observed to reduce and minimize the risk of falls. Swann (2010) also added that unsafe clinical areas like broken and wet floor can cause falls.

Barker et al (2010) stated there are many assessment tools in the hospital setting to help prevent falls and there are key measures to successful prevention, recommended by many clinical practice guidelines. However those tools are not effective if they are not used appropriately and if healthcare professionals do not evaluate them. Therefore it is the nurse’s responsibility for updating these tools, as assessment is on-going process and patient’s conditions may change.

Oliver et al (2008)  advise that 10 years ago there was a practice  risk a assessment tool for rehabilitation published and delivered in the UK for elderly as well as for acute wards known as the St Thomas’ Risk Assessment Tool (STRATIFY). This fall risk assessment tool is to identify high or low risk of falls and have been designed in five simple scoring systems from 0- 5 to predict who may be at risk of falls. According to Kennedy (2010) nurses should have special training to use the STRATIFY risk assessment tool which will raise awareness when used in practise to prevent patients from falls to protect them from further harm or injury.

Milisen et al (2007) described in their purposive multicenter study where they evaluated the effectiveness of the STRATIFY fall assessment risk tool. The study was carried out in six Belgian hospitals, the sample size was 2,568 participants mixed female and male and the average age was 67.2 ranging between plus and minus 18.4. The study was carried out in a four surgical, eight elderly and four medical units. The findings of this study show the effectiveness of the STRATIFY tool in the admission of patients in medical and surgical settings for patients younger than 74 show that assessment predict risk of falls well for this age group category. However it was not as successful when measured against an older population, above of 75-85 age range that are admitted in the elderly ward. For older patients with prolonged residential hospital care, it is unclear whether repeated use of the STRATIFY tool would enhance its clinical effectiveness. Furthermore, the study identified  that the risk of falling, as measured on admission is not static and as a result the risk of falling during their subsequent hospital stay must be calculated and updated on a weekly basis.


Smith et al (2006) did a similar study on the STRATIFY assessment tool for patients recovering from strokes.  Six stroke units in North of England with 359 participants were selected where they used this assessment.  Every member of staff was trained to use the tool. They average stay was 28 days and the age range was between 34 and 100 years.  Within this group, STRATIFY underperformed as a predictor of falls occurring in the 28 days following the initial assessment. Using the currently recommended score threshold (2 or more as high risk), STRATIFY was found to be inaccurate with a sensitivity rating of just 11.3%. The optimum STRATIFY threshold for our stroke patients was a score of one or more, but even optimising the risk indicator resulted in a sensitivity of just 60% and this was achieved at the expense of specificity.  This study also highlights that some of the questions were not appropriate for all stroke patients as they were not applicable such as mobility questions as well as the amount of falls since they have been admitted to hospital.

Nazarko (2008) stated that there are further methods to manage risk management in falls and one of them is to assess the location of the nurse’s station which can play a crucial role in risk management especially amongst the elderly population. If patients are located in single rooms and out of sight from nurses and other healthcare staff, there is a greater risk in falls as staff are unable to identify those at risks and react as speedily to patients who are in need of assistance. For this reason, most of the patients hospitalized in wards who may be at risk of falls are moved closest to the nursing station, to assist nurses’ visibility and reduce the impact of falls. However, it is not possible to implement this practice in nursing homes with single rooms or any other wards where patients are located in single rooms.

Downing (2011) states that there are more interventions that serve to improve patient care,  particularly amongst the elderly, such as the electronic alarm device which is located on the patient’s bed or chair. Every time the patient attempts to get up it will sound so that healthcare assistants can assist the patient before any fall can occur. These devices can help with high-risk patients who are confused or have got dementia. Pountney (2009a) also recommends the alarms which can be used for patients whosuffer from dementia or are confused and also add that light sensors can improve people from falls. According to Nazarko (2006), bad vision could be a major impact on patient’s falls, as up to 74% admitted patient from falls had a poor vision. Therefore falls cannot be removed but management may improve quality of life for those patients to use those light sensors, especially if patient is located in single rooms out of sings of nurses.

Another option, Vitamin D supplements, are  identified as having a role to play in mitigating the impact of falls, as Vitamin D make bones stronger and as a lack of Vitamin D can have a affect on weakness of muscle and bones. The NHS National Institute for Clinical Excellence (2004) however, do not recommend Vitamin D asthey feel there is inconclusive evidence advocating its use. According to Help the Aged (2004) risk assessments and monitoring will not guarantee to stop people from falling, however nurses will be able identify through assessment of potential risk to minimise this and improve patient safety with appropriate action taken.

Pountney (2009a) further emphasises that the requirements of risk management must be weighed against the need to empower patients to remain independent and must not overpower the quality aspects of their everyday routine. The aim is to minimize patients from injury but also to encourage their mobility for better quality of life. Therefore managers have got a responsibility for managing risk against effective policy, ensuring staff are fully trained, as well as fostering a good environment to minimize risk of falls to support patients’ well being, as well as quality of life Pountney (2009b)


Nazarko (2009) states some patients with conditions generally affecting the elderly such as MS and Parkinsons disease may have many falls but if
the opportunity to walk is removed to prevent falls, it is regarded as more harmful as the patient will have reduced confidence and independency. Nazarko (2009) agrees withSwan (2007) that most of the falls that occur in hospitals are not major injuries, however any falls can have a major impact on each patient as they may lose their confidence as well as dignity.  The patient’s quality of life may change dramatically as they may not be able to undertake daily activities. A loss of confidence and the inability to undertake daily routine can make the patient weaker as well as make the patient feel more isolated (Nazarko 2009).

Pountney (2009) state that a lack of training of staff on falls can have a negative impact on patients which will cause inappropriate practice, but also further state that this can cause the unwanted implication to staff, where nurses will have to deal with complaints and increased workload, which leads to increased anxiety. According to Mitchell (2007), one of the major management tools to prevent falls is through the education of staff, as well as patients. Therefore nurses and other healthcare professionals who have contact with patients must have easy access to the tools, whether e-learning or manual.  Whichever one is more suitable for the individual and encompasses as minimum basic skills to maintain acceptable practice. To provide best practice in falls prevention, audits must also be carried out on a regular basis.

The author used examples to explain why they chose risk management in falls as a topic.This essay explained what risk is and how risk must be identify before any action is taken. The evidence has also found that if we learned from previous mistakes risk could be reduced as improving patient safety which ultimately reduces costs. The five easy steps of HSE risk assessment were highlighted as best practice throughout the healthcare setting.

This statistics provided from England and Wales as well as statistics from Scotland, demonstrated the widespread issue that falls are a major problem for the elderly population outside as well as inside of the hospital settings. Moreover various study show that most falls happening in nursing homes.

The essay also focused in-depth at two studies analysing the effectiveness and appropriateness of the STRATIFY risk assessment tool. Both studies were using the STRATIFY assessment risk tool in different healthcare settings. Furthermore studies show that STRATIFY assessment risk is successful for the younger population but not as successful with older population over 75 and also that it did not appear to be helpful with stroke patients as some questions were inappropriate.

There was a focus on how falls could be prevented as there are so many different reasons for patients having a fall. For some of them it could be due to their illness, medication, nursing station location, whether it is morning or night. This essay illustrates the critical role nurse’s play in providing the best possible care and support to patients. Nurses should be specially trained and educated to provide the best care to minimise patients from falls and maximize patients protection.



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