Becoming fall-safe: a framework for reducing inpatient falls

Abstract

This article describes a 10-year programme of work that has reduced inpatient falls rate by 46% and how this improvement has been sustained. The methodology applied in this initiative has forced one Trust to challenge expectations about the inevitability of patient falls in hospital. This initiative has resulted in approximately 568 fewer falls each year. Based on costings from NHS Improvement, the estimated 5108 fewer falls between 2011 and 2019 have saved the Trust £13.3 million.

Full text

1198 Britis h Journa l of Nursin g, 2020, Vol 29, No 20
PROFESSIONAL
I
npatient falls are the most commonly reported patient
safety incidents in the NHS. The most recent Organisation
Patient Safety Incident Reports (OPSIR) workbooks
based on data submitted to the National Reporting and
Learning System (NRLS) covering the period April
2018 to March 2019 reported 228 503 patient accidents in
acute (non-specialist) hospitals in England and Wales. The vast
majority of these patient accidents would be patient falls and
the number suggest more than 600 patients fall every day (NHS
Improvement, 2020a; 2020b). With statistics like these, it is easy
to see why inpatient falls are often viewed as ubiquitous and
inevitable in hospitals. All falls, even those that do not result in
injury, can cause patients and their families to feel anxious and
distressed. For those who are frail, minor injuries from a fall
can aect physical function, resulting in reduced mobility and
undermining patient condence and independence.
Based on data presented in an NHS Improvement report
on the incidence and costs of patient falls in hospitals (2017),
the authors calculated that there are 5310 serious injuries per
annum in hospitals in England, including hip fractures and head
injuries, which can result in patient death. Falls in hospitals are
also expensive as they increase the length of stay and may require
increased care costs on discharge. NHS Improvement (2017),
calculated that the average cost of a fall in hospital is £2600.
This project started in the nancial year 2009–2010 at
Brighton and Sussex University Hospital (BSUH) NHS Trust,
at which time the Trust’s incident data recorded 1400 falls
and reported a rate of 6.23 falls per 1000 bed-stay days. This
rate was slightly lower than the national falls rate of 6.63 per
1000 bed days, as reported by the Royal College of Physicians
(RCP) in 2015.
There was a commonly held assumption that falls were an
unfortunate side eect of a patient’s rehabilitation or an unavoidable
part of their deterioration into frailty. Such cultural norms and
expectations served to reinforce sta perceptions that falls were
inevitable, which can then become a self-fullling prophecy.
Background and literature review
The journey to reduce falls at BSUH began in April 2009. The
catalyst for this work was, unfortunately, far from unique: a
catastrophic fall leading to the death of a patient, a bereft family,
guilt-ridden sta and damning media coverage. The Trust’s Chief
of Safety made a commitment to the family of the deceased
patient to reduce the number of inpatient falls in the Trust,
mindful of the fact that tackling the problem of inpatient falls
is a huge challenge. The falls project team reviewed Cameron
et al’s (2010) Cochrane review of interventions for preventing
falls, which concluded that there are no ‘quick x’ interventions
that, when implemented on their own, signicantly reduce the
rate of inpatient falls.
The timeline of the project is shown in Table 1.
Methodology: a traditional approach
In the rst falls project in 2009, the falls project team applied a
traditional change methodology, organising a Trust-wide launch
of a falls programme, ensuring that every ward manager could
attend. To emphasise the importance of this initiative, the team
invited a national expert on falls to educate sta, a renowned
speaker on leadership to inspire sta, a doctor passionate about
reducing patient sedation as a strategy for reducing patient falls
and physiotherapists and occupational therapists keen to work
collaboratively with nurses.
At the launch, the ward managers and occupational therapists
were given individualised reports detailing the number, rate,
time, and other specic details of falls on their wards. Similar
© 2020 MA Healthcare Ltd© 2020 MA Healthcare Ltd
Becoming fall-safe: a framework for
reducing inpatient falls
Mark Renshaw, Paula Tucker and Karen Norman
ABSTRACT
This article describes a 10-year programme of work that has reduced
inpatient falls rate by 46% and how this improvement has been sustained.
The methodology applied in this initiative has forced one Trust to challenge
expectations about the inevitability of patient falls in hospital. This initiative
has resulted in approximately 568 fewer falls each year. Based on costings
from NHS Improvement, the estimated 5108 fewer falls between 2011 and
2019 have saved the Trust £13.3 million.
Key words: Patient falls ■ Patient safety ■ After action reviews
■ Complexity science ■ Reective practice
Mark Renshaw, Head of Quality Improvement, Brighton and
Sussex University Hospital NHS Trust, mark.renshaw@nhs.net
Paula Tucker, Deputy Chief Nurse, Innovation and Improvement,
Surrey and Sussex Healthcare NHS Trust
Karen Norman, Visiting Professor, Complexity and Management
Group, University of Hertfordshire, Visiting Professor, School
of Nursing, Kingston University and St George’s, University of
London, and Non-Executive Director, Queen Victoria Hospital NHS
Foundation Trust, East Grinstead
Accepted for publication: June 2020
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British Journal o f Nursing , 2020, Vol 29, No 20 1199
PROFESSIONAL
wards were grouped together in facilitated workshops to enable
variations in performance to be compared and discussed. At
the end of the workshop, each ward manager left with an
individualised action plan, detailing how they were going
to reduce the falls rate on their ward. Collectively, the ward
managers identied 150 actions that they and their teams
were going to take to reduce the number of falls in the Trust.
The initial results appeared promising, indicating a reduction
in the monthly rate of falls. However, by the third month the
rate of falls had fallen back into a pattern of normal variation.
At the 3-month follow-up meeting, the wards reviewed their
compliance with the action plans and generated new ones.
This pattern continued for the rest of the year and, despite
the considerable eort exerted into reducing the rate of
falls, it remained stubbornly xed, seemingly impermeable
to change (see Figure 1). The review of performance in the
rst year divided opinion. Some ward managers genuinely
believed progress was being made and pointed to the analogy
of stars in the midnight sky: that the harder one looks, the
more you will nd, arguing that by focusing the ‘telescope’ on
falls, more reporting was encouraged. Others suggested that
the evidence base for falls reduction was weak, conrming
their original contention that falls were inevitable. Another
group suggested that the wrong actions had been chosen,
or that sta were just not implementing them, or had not
understood them.
With hindsight, the falls project team can now see that they
followed a common approach to safety and quality initiatives
when quality targets are not met. This was, namely, identifying
best practice (guidelines, policies, care bundles, action plans
etc) and monitoring performance to check this was done. If
results failed to improve, more of the same was done; that
is, more detailed guidelines were produced, there was more
frequent scrutiny, and even more action plans. Although the
team believed the latter can be necessary and useful, a point
raised by one member made the team start to question this
approach. They said:
‘We’ve done everything agreed. If a drug didn’t
seem to be working, would we keep giving it to
the patient?’
This challenge provoked the project lead to start to question
the underpinning theoretical assumptions behind this approach
to quality improvement.
One of the observations during the course of this initiative
was that much of the evidence base tells you ‘what to do’. The
real challenge is making this ‘what you do’ to incorporate best
practice into your daily activity.
By early 2010, it was clear that despite the project team’s
best eorts, this approach was not going to deliver a signicant
reduction in falls. Simultaneously, the team was beginning to
consider alternative explanations for the results from the rst
year and developing a hunch that proved to be the key to
unlocking the eventual approach to reducing the falls rate.
This hunch went beyond locating responsibility for reducing
falls primarily with ward leaders and was informed by insights
from improvement methods inspired by complexity theory
(Suchman, 2011).
The project team became interested in whether the behaviour
of nurses on the ward could be inuenced so that they were ‘falls
aware’. The team also speculated that, if one individual member
of sta behaved in a falls-aware manner, this behaviour might
spread to other individuals who came into contact with this
individual—in much the same way as a virus spreads through
a group. Buchanan (2007) highlighted that we are, by our very
nature, born imitators:
‘We do not think entirely on our own, what
we believe and why depends strongly on
our interaction with others… [The] roots of
imitative behaviour … seem to be automatic
and unconscious, and instinctual, hardwired into
© 2020 MA Healthcare Ltd
Table 1. Project timeline
Date Event
April 2009 Catastrophic fall on acute medical ward
July 2009 First Trust-wide falls project launched (falls rate reduced from 6.23 to
6.07 per 1000 bed days)
April 2010 Second falls project launched (eight-ward pilot—falls rate reduces from
9.1 to 6.6 per 1000 bed days)
April 2011 Third Trust-wide falls project launched
2012–2013 Falls rate drops below 5.5 per 1000 bed days
2013–2014 Falls rate for previous 12 months drops to below4.2
2014–2016 Falls rate for previous 12 months drops to below3.5
2016 Senior nurse joins a neighbouring trust
2016–2019 Annual falls rate drops below 3.4
Figure 1. Results of rst-year Trust-wide project and second-year eight-ward pilot
Fall rate per 1000 bed days
10
9
8
7
6
5
4
3
2
1
0
Initial falls rate
(July 2008—
June 2009)
Falls rate at
end of year 1
(July 2008—
June2009)
Initial falls rate
2nd year, 8 wards
pilot (April 2009–
March 2010)
Falls rate at end of
2nd year, 8 wards
pilot (April 2010—
March 2011)
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1200 Britis h Journa l of Nursin g, 2020, Vol 29, No 20
PROFESSIONAL
our biological makeup. We may go through life
thinking that we make up own mind but the
reality is that when people are free to do as they
please they often imitate each other.’
Buchanan, 2007
All too often it is these acts of imitation that bring our
public bodies into disrepute; examples include the Panorama
exposé of practices at the Winterbourne View care home in
Bristol and the Mid Staordshire NHS Foundation Trust public
inquiry (Francis, 2013). When the degradation of patient care
spreads through an institution, the team speculated that imitation
appeared to be the vehicle. Believing imitation to be a powerful
force, it was decided that, rather than taking the usual option of
prescribing to sta what they should do through policies and
guidelines, the team would focus on how individuals should act
on a busy ward to reduce the likelihood of their patients falling.
Methodology: implementing an emergent
design approach
As an alternative to the planned approach used in the
rst year, the project team adopted a model referred to as
‘emergent design’. The team abandoned the action plans
and instead encouraged a mind-set of curiosity, exibility
and experimentation with the notion that ‘not knowing’ is a
virtue, not a deciency. Rather than planning many stages in
advance, by using an emergent approach, the next step was
only planned when the results of the previous were seen. This
allowed opportunities to identify and utilise emergent patterns
and ideas. The concept assumes there is no ‘silver bullet’; small
changes are continuously introduced hoping that some will
have a ripple eect and encourage other changes (Suchman,
2011). Another similar approach of ‘try a lot of things, keep
what works’ has been found to be the basis for sustainable
success in larger corporations (Collins and Porras, 1994).
A well-respected senior nurse was recruited to lead the
project. Although she did not see herself as an expert in falls,
sta recognised her as a leader with high professional standards,
unafraid to challenge the status quo, and with an intellectual
curiosity that sought to question and account for the rationale
behind the professional actions of all involved in the delivery
of patient care. Multifactorial complex problems such as falls
have a tendency to be a challenge when applying the dominant
approaches to quality improvement, such as care bundles,
guidelines, educational programmes, action plans, etc. Instead,
the project team acknowledged that no one individual, the
project lead included, held all the answers to reducing the
Trust’s falls rate.
Utilising the Trust’s online incident reporting system, the
senior nurse augmented the incident investigation process to
include an after action review (AAR) debrief following each
reported fall. The AAR process facilitates reection and feedback
on individual, team and collective performance, in a non-
confrontational fashion, with the spirit of an AAR being one
of learning not blame. Schindler and Eppler (2003) suggested
that creating an atmosphere that is conducive to encouraging
openness and trust are crucial goals of the process to enable
team learning, team building and team integrity.
An AAR is based around four overarching questions:
■ What was expected to happen?
■ What actually happened?
■
Why was there a dierence between what was expected and
what actually happened?
■ What are the lessons that can be learnt?
The process was designed to establish the extent of the
decit between the expectations of those involved and the facts
surrounding each adverse event (Morrison and Meliza, 1999;
Schindler and Eppler, 2003).
In practice, this meant that the senior nurse was alerted
immediately, via email, to every fall as soon as it was reported
via the Trust’s online clinical incident reporting system, a well-
established system that had been in use since 2007. This rapid
notication fostered maximum opportunities for immediate
learning via the AAR for everybody involved with the care
of the patient who had fallen. The AAR framework provided
© 2020 MA Healthcare Ltd
Table 2. Falls interventions
1. Ensure that the call bell is within reach, is working and that the patient can use it
(consider other ways of communication if required)
2. Ensure that footwear is non-slip, low heeled and well-tting. Check hospital slipper
socks daily for grip. Check feet, refer any problems to podiatrist
3. Ensure that spectacles are within reach and are clean
4. Urinalysis to be taken on admission. Respond to requests for toilet facilities with
urgency—within no more than 5 minutes (consider communication needs)
5. Ensure the correct use of hearing aids
6. Assess needs/ensure walking aids are appropriate and within reach at all times
7. De-clutter bed space
8. Ensure that personal belongings are within easy reach
9. Discuss normal activities of daily living with patient and carers
10. Nurse in high-visibility bed
11. Nursing staff to accompany/be within arms reach of patient for high-risk activities
such as dressing, toileting, etc
12. Assess frequency of ‘comfort/toileting rounds’. Implement toileting chart
13. Request medication review is undertaken on ward round
14. Perform bed rails assessment
15. Consider referral to falls clinic
16. Refer to physiotherapist for range of movement, strength, balance and/or
gaitexercises
17. Identify risk of falls on handover sheet; ensure that all staff are aware of risk status
18. Check lying and standing blood pressure using manual sphygmomanometer at least
three times a week at different times of day. Report any postural drop to medical
staff for their review
19. Assess the need for increased supervision/observation—consider one-to-
onespecialing
20. Implement multidisciplinary visual observation chart
21. Consider low-level bed
22. Assess for suitability for bed/chair alarms
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British Journal o f Nursing , 2020, Vol 29, No 20 1201
PROFESSIONAL
a structure for talking about what was expected in relation to
how to act in a way that minimised the chances of the patient
falling again and future patients from falling. At the same time,
the debriefs allowed the opportunity to review the dierence
between what was expected and what actually happened. The
expectation–reality decit was identied for each patient fall
and the ward sta were given the opportunity to discuss and
reect on how events might have been prevented and how
local systems or patterns of working could be improved. The
emphasis was on constantly improving the learning about falls
in each specic local context with the sta involved in caring
for the patient that had fallen, thus empowering sta to aect
change rather than portraying the process as punitive.
The focus was exclusively on the local context of the ward—
its layout, patients, stang and leadership were critical. The
senior nurse was also mindful of generalising the results to a
wider context. For example, when intentional toileting made
a dierence on one ward, the results were shared but not
imposed on other wards. Thus through continuous AARs,
wards learnt how to manage the risk of patients falling on
their individual ward.
The AAR debriefs were with the sta directly involved in
the care of the patient who had fallen (and when possible also
the patient) and focused on exploration of their expectations
of the outcome of their actions prior to the patient falling.
Insome cases, they had not anticipated the risk of a fall;
in others, they had been forced to make pragmatic choices
between other care priorities for patients, which had been
judged to be of greater importance at the time. An important
nding was that in these group reections, the senior nurse
moved beyond the more conventional use of the AAR tool as
solely a technique for identifying a ‘root cause’ of the fall, to
engaging in reexive acts of imagination and exploration of
future consequences andcreative challenge to local constraints
and habits such as‘theway it is around here’ or ‘we’ve always
done it like this.’
Learning was generated by working with frontline sta in
developing safety solutions, which resulted in the continual
updating of mutual expectations around nurses’ behaviour in
relation to falls-aware practice. Instead of being told what to
do solely through policies and guidelines, it was contended
that it is the sta delivering the care who hold the answers to
improving the safety of care. At that time, the project team’s
belief was that behaviours spread through social groups by
imitation, thus, if one nurse (particularly, an inuential nurse)
acts in a certain way, this increased the likelihood that others
will follow this individual’s behaviour through role modelling
(Buchanan, 2007). As this approach has focused on behaviours
(and behaviours are habitual), the team contended (as evidenced
by the consistent falls rate in recent years) that because habits
are hard to break, sustainability is built into the programme for
the reasons explained below.
Sta were encouraged to develop practical ideas on how they
would prevent the recurrence of falling. All ideas were embraced
and tested through constant measurement of the wards’ falls
rates. Through countless iterations, the expectations around
falls-aware practice evolved. An example of this would be:
■ A patient with a high falls risk should have a rapid response
when they use the call bell. This becomes a habit
■ The patient still falls as they are left alone in the toilet
■ The patient’s call bell is answered rapidly and a member of
sta waits for the patient while they are in the toilet in order
to accompany the patient back to bed.
This challenged the notion of ‘best practice’ as something
fixed, towards it being understood as something that is
continuously evolving and being re-tested in a local context. It
also highlighted the idea that ‘best practice’ is not a simple rule to
follow, devoid of the need for re-evaluation and consideration of
the application of the rule locally. For example, this might mean
weighing up the competing values such as ‘patient safety’ with
others such as ‘maintaining dignity’ when choosing whether
to remain present while the patient uses the toilet. If a familiar
practice delivers an outcome that is unexpected or detrimental,
it makes sense to re-evaluate whether or not it is still the right
thing to do. If not, an alternative emerges through acts of group
reection in the AAR. If that worked, we found the revised
practice becomes habituated because it then seemed the obvious
thing to do. This is in line with the pragmatic tradition that
underpins the team’s approach (Stacey and Mowles, 2016).
The continued focus on expectations, and the evolution of
these expectations in conjunction with the immediate discussion
and re-examination of the project team’s expectations of ‘falls-
aware’ behaviour meant that learning from each specic fall
was immediately translated into practice rather than through
a written action plan to be enacted at a later date.
When talking about this work, the team is often asked
for practical examples of what they do. The policy is that all
patients are risk assessed on admission for any known risk
factors that may precipitate a risk of falls. These include
age, a history of falls, mobility, level of comprehension, any
sensory impairment, medication, sleep patterns, neurological
problems and continence. Other factors such as alcohol abuse,
anticoagulant therapy, postural hypotension, recent surgery,
sepsis or epidurals are also taken into account.
The assessment chart includes practical suggestions (see
Table 2) for how sta can mitigate the risks of their patients
falling, ranging from practical issues such as ensuring the bedside
area is clutter-free, through to measures such as the need for
increased supervision and observation, consideration of one-to-
one specialing, (enhanced patient supervision by nursing sta)
and the implementation of the Trust’s multidisciplinary visual
observation chart. Consideration is also given to the use of a
low-level bed and the patient is assessed for suitability for a bed
or chair alarm. In the event of a patient falling, an algorithm
is followed for post-fall management and care. Each fall is
reviewed to ensure that lessons are learnt, as outlined above.
This may include further revision of both the risk assessment
tool and the falls action care plan for that patient.
The focus was on exploring each fall and nding solutions
within the existing resources. As the falls rates fell, the team
asked sta what had made the most dierence. One replied:
‘I don’t know, but preventing falls just seems
more at the front of my mind.’
© 2020 MA Healthcare Ltd
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1202 British Journa l of Nursin g, 2020, Vol 29, No 20
PROFESSIONAL
It was also noticeable that sta were beginning to behave
dierently, for example, asking if a patient was high risk before
they were transferred into their ward and automatically putting
them in a high-visibility area if they were. Or, accompanying
the patient to the toilet and waiting for them rather than leaving
them alone in the bathroom. These subtle shifts in behaviour
and in how sta were talking about falls have, the authors argue,
collectively made a big dierence to the falls rate, as outlined
in the resultsbelow.
Results
In the second year, as well as changing the theoretical approach
to the project, the team also curtailed its ambition by focusing
on one geographical block that housed eight elderly care and
medical wards. This block was chosen as it accounted for almost
a third of the falls in the Trust and the wards had some of the
highest falls rates in the hospital. During the rst year, these
eight wards reported 484 falls at a rate of 9.1 falls per 1000
bed-stay days. In the second year, the rate of falls was reduced
by 29% to 6.6 falls per 1000 bed stay days. As Table 3 illustrates,
six of the eight wards reduced their falls rate during 2010-2011.
During 2011-2012, the BSUH project expanded to focus on
reducing the rate of falls across an additional 31 acute inpatient
wards, which between 2011 and 2019 accounted for 84% of the
Trust’s total number of falls. Areas excluded from the programme
included intensive care, maternity and paediatrics as these areas
had a relatively low rate of falls. Accident and emergency was
also excluded as it does not have beds and therefore it was not
possible to calculate a rate. Similarly, outpatient clinics, discharge
lounges, dialysis units and day case areas were also excluded.
Table 4 and Figure 2 illustrate that the annual falls rate has
continued to decline, with a rate of approximately 3.4 falls per
1000 bed days being sustained over the past 5 years (despite the
absence of the senior nurse who left the Trust in 2016). By the
end of the year 2018–2019, the overall reduction in falls was
46%, based on the rate in 2010–2011 of 6.23 falls per 1000 bed
days. Based on costings from NHS Improvement, the 5108 fewer
falls between 2011 and 2019 saved the Trust £13.3 million.
Limitations
It should be noted that between 2009 and 2018 the Trust
opened new wards and closed some services. For the purpose
of consistency, analysis in this article only contains data on those
wards that remained unchanged. The project team was conscious
that the measurement of the impact of this initiative was reliant
on self-reported data (clinical incidents). Throughout the initiative
the team constantly monitored the distribution of reported falls
each day using the Poisson distribution. This approach allowed
the team to calculate the probability of a certain number of
reported falls on any particular day, while comparing this to the
actual number of reported falls. Over the duration of this project
course compliance or t against the Poisson distribution curve
rose from 86.8% in 2009–2010 to 94.2% for the wards involved
in the second falls project. A nding that suggests the focus on
falls did encourage a greater level of reporting.
© 2020 MA Healthcare Ltd
Table 4. Falls rate and number of falls 2009–2019
Yea r Reported falls Bed days Falls rate per
1000 bed days
Cumulative %
difference since
2010−2011
Number of falls
saved (based on
rate of 6.23)
Financial saving
(£)
2011–12 1401 242553 5.78 -7.27 110 286 273
2012–13 1356 249497 5.43 -12.75 198 515 752
2013–14 1088 263285 4.13 -33.66 552 1 435 890
2014–15 895 257454 3.48 -44.19 709 1 843 240
2015–16 896 261827 3.42 -45.06 735 1 911 474
2016–17 877 261603 3.35 -46.18 753 1 957 245
2017–18 845 252819 3.34 -46.34 730 1 898 162
2018–19 862 255091 3.38 -45.75 727 1 890 764
Total 8220 2044129 5108 13 280 539
Table 3. Falls rate for the eight wards involved in the second falls project
Ward April 2009— March 2010 April 2010—March 2011 % difference
in falls rate
2009–2010
to 2010–
2011
Reported
falls
Falls rate
per 1000
bed days
Reported
falls
Falls rate
per 1000
bed days
Ward 1 32 5.3 32 5.3 -0.3
Ward 2 75 11.5 36 5.0 -56.3
Ward 3 28 3.3 42 5.3 60.6
Ward 4 104 16.2 59 8.0 -50.5
Ward 5 39 4.3 60 7.3 47.2
Ward 6 51 8.2 42 5.7 -30.6
Ward 7 54 9.57 43 6.9 -28.3
Ward 8 103 16.3 63 9.4 -42.5
Total 484 9.1 376 6.6 -27.5
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British Journal o f Nursing , 2020, Vol 29, No 20 1203
PROFESSIONAL
Discussion
It was evident at the early stages of this initiative that there was a
generalised attitude and belief that falls were largely unavoidable
and therefore it was accepted that patients may fall while in
hospital. The work by the project team and nursing sta over the
past 10 years has reinforced the team’s belief that understanding
how such nursing behaviours and beliefs arise is the key to
reducing patient falls. The initial hunch about the importance
of imitation and positive role modelling in facilitating falls-
safe behaviour and habits to spread through the Trust’s ward-
based teams was a helpful starting point, but a research grant
and subsequent study enabled a more detailed understanding
about the processes involved in changing professional values
and norms regarding falls-safe practice (Norman et al, 2015).
The project team’s ndings built on and developed the initial
assumption (informed by change and educational theories
worked with over the years), that people learn through mimicking
others more experienced or powerful than themselves, and that
knowledge is something that is transferred from an expert to a
novice, led to a dierent understanding of behaviour change,
drawing on the pragmatic tradition (Mead, 1934). It became
evident from the team’s research that there was much more
going on in the complex social interaction between the senior
nurse and sta than ‘role modelling’ or simple mimicry.
By adopting the AAR framework in the way described,
where reexive conversation, rather than completion of the
clinical incident investigation form (previously normally
completed by the most senior sta for the sake of expediency,
if at all), was the main focus, the project team recognised that the
practising nurses and healthcare assistants often held the solution
to many complex safety and quality problems. Thus the specialist
expertise of the senior nurse involved the skilful facilitation of
the debrieng, providing reexive space in which she and others
were able to have potentially dicult conversations about who
had done what and why.
The project team recognised that such conversations had often
been avoided, because it was felt that they may cause conict and
provoke strong emotions, especially if the patient has sustained a
serious injury. Sta reported feeling guilty, ashamed, angry and
blamed—both with themselves and with each other. They often
found it hard to talk about such feelings, both because of fear
of being blamed themselves, or of upsetting others by calling
their professional judgement and practice into question. This is
consistent with pragmatist John Dewey’s denition of reection
as ‘the painful eort of disturbed habits to readjust themselves’
(Dewey, 1922; Brinkmann, 2013). Thus as our habits become
problematic in each local context, we formulate conscious ideas
that are tested through active action, ie in this way of thinking,
thought is action, rather than something that precedes it, as
assumed in the action-planning activities described earlier. The
AAR debrieng provided the opportunity for the ward team to
develop a shared understanding about possible causes for each
fall, and renegotiate together whether their habitual practices
(norms) for falls prevention were t for purpose in their specic
local environment. In this way of understanding, learning arises
from their shared reection about a specic incident, after which
it no longer makes sense to follow previous habits of practice.
This is because sta expectations about the possibilities of the
outcomes of their actions/inaction are no longer the same, due
to the insights gained from hearing other sta ’s perspectives
about what happened when a patient fell, why they all did
what they did, and the unforeseen consequences of their own
actions and the actions of others. Although initially anxiety-
provoking for all concerned, as the debriengs became the norm
and valued by those participating, something seemed to shift,
with sta coming to see themselves as having the potential to
inuence the emergent patterns of practice in their ward, both
by their actions and omissions.
Subsequent research (Norman et al, 2015), helped the project
team to recognise that what also shifted fundamentally was how
sta were talking more frequently about preventing falls, and
also how they were talking about this topic. As Shaw noted:
‘Conversation itself is the key process through
which forms of organising are dynamically
sustained and changed.’
Shaw, 2002
The project team concluded that the capacity of the ward
teams to keep alive this narrative theme and its ongoing
evolution may be one of the main reasons for sustaining the
lower falls rate after the senior nurse leader left the project.
The subsequent wider conversations between wards in this
growing community of practice identied generalised themes
about what constituted falls-safe practice and these were then
re-tested and adjusted once again in each specic ward situation.
As one clinical manager noted in one of our focus groups when
asked what had changed their mind:
‘So what’s changed is that, rather than saying,
“Okay we’ve had a fall last night, okay, is she
alright? Yes, she is ne.” [Instead] it’s, “You’ve
had a fall; have you done the after action
review? Yes? What was the learning? What have
you done now? What actions have you put in
© 2020 MA Healthcare Ltd
Figure 2. Rate of inpatient falls per 1000 bed days 2009 to 2018
Falls rate per 1000 bed days
2009–
2010
2010–
2011
2011–
2012
2012–
2013
2013–
2014
2014–
2015
2015–
2016
2016–
2017
2017–
2018
2018–
2019
7.00
6.00
5.00
4.00
3.00
2.00
1.00
0.00
Years
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1204 British Journa l of Nursin g, 2020, Vol 29, No 20
PROFESSIONAL
place to remove that?” “Well, I’ve moved that
patient into a high visibility bed.” Or: “Have
you put the falls alarm on?” It’s just linking
it all, in a more intelligent way, rather than,
“What a shame, is she okay? Is she ne? Okay,
well then, ne,” and just moving on, rather than
learning from that.’
The manager also said:
‘And I think that learning comes over time, you
don’t instantly learn ... after one after action
review, it’s that knowledge we’re building on
a ward, within that community, to allow them
to see things and prevent them before they
happen …You know, what’s been done, it’s like,
instinct, it’s a normal reaction for this to the
information, this is what we’ve done, and this is
what we’re going to do to prevent it. I just think
we are more intelligent.’
So rather than seeing ‘best practice’ as something located
‘in’ an expert who empowers others, or a policy or guideline,
sta now see this as an ideal, a value, which is constantly tested
in practice, which may require further investigation and need
revising when this fails to deliver what was expected or they
are surprised in some way. The project team also learnt that
nurses’ knowledge of falls prevention was seldom the problem
in terms of falls awareness when assessing and documenting
the risk of patients falling. This helped explain why approaches
such as ensuring sta are aware of policies and guidelines while
having some impact, on their own failed to yield the more
radical improvements shown from year 2 onwards. The real
challenge arose when sta had to make contextual judgements
about falls-safe practice in complex situations, with competing
priorities, in which every patient and each ward setting is
slightly dierent and best practice is more nuanced than simply
following the protocol, as in the above example, where beliefs
about patients’ dignity and privacy conicted with those of
safety when deciding whether or not to stay with a frail patient
who was using the toilet.
Conclusion
Rather than now seeing falls solely as either a ‘systems’ problem
(system failure), or one that locates the cause of the fall with
individual sta (poor performance or lack of competency),
as informed by the traditional improvement methods taught
at the start of the project in 2009, the Trust’s falls reduction
programme drew on insights from complexity science and
its helpful concept of emergence. In this way of thinking, a
fall is understood as an event that emerges out of the micro-
interactions between nurses and their patients, that is, because
of what everyone is doing/not doing. From this perspective,
relationships are fundamental and falls emerge from complex
interactions, and not in isolation. This understanding emphasises
the importance of the interactions between individuals, groups
and their environment, since this determines the prevailing
culture and the likelihood of a patient falling. Rather than
solely training sta about techniques of falls prevention, as
in the rst year of this project, the senior nurse also worked
with ward teams, supporting ward managers in facilitating
post-fall debriefs. The project team concluded that it was
during her conversations with sta about their expectations
of their ‘fall-safe’ interventions in the light of each specic
fall, that new insights emerged about fall-safe practice that
were either accepted or rejected. In that sense, the team now
see such reexive conversations as ‘the work’ of the change.
If sta come to see that a previously regarded intervention
has the potential for harm, this is called to mind next time
another intervention is required. Usually, it no longer makes
sense to carry on doing what they did before, or, at the very
least, they are able to imagine how they would give an account
of their choice in the light of what they had learnt. As a result
of the nonlinearity of these interactions, small changes can
have large eects. The falls rate in the Trust has come down
progressively since 2010.
By the project leads participating in and co-creating a habitual
way of reecting, together with those involved in situations in
which patients have fallen, dierent conversations and practices
emerged and the culture and the narrative in relation to falls has
shifted away from seeing falls as an inevitable part of a patient’s
pathway to frailty. It is important to note that the authors are
not suggesting that there is a ‘special’ way of communicating
that individuals can learn. A central insight from this work
(backed by the initial hunch of the project lead regarding how
poor practice might spread) is that is in our ordinary everyday
complex processes of relating—how we converse about who
we are and what we think we are doing—cultural patterns of
behaviour emerge. These are then judged retrospectively (and
sometimes dierently) by ourselves and others to be either ‘good’
or ‘bad’ practice. This work has emphasised that teamwork is a
practice, often involving conict, as values and expectations are
contested and renegotiated. Keeping wider perspectives than
our own in view may help oer a broader range of choice to
sta facing complex situations where there may be conicting
safety demands that they have to prioritise.
The project team would argue that it is this process of habitual
reection that has led to the emergence of new behaviours.
The fact that the behaviours tend to be habitual also explains
the sustainability of the falls rate after the nursing lead left the
Trust in 2016.
Our experience over the past 10 years has led the project
team to conclude that a substantial number of inpatient falls
are preventable. It is an old adage that ‘conversations are the
mainstay of safety.’ This is why this approach emphasised the
importance of paying careful attention to how people are talking
about them. If these results were replicated across the NHS
this would equate to 105 800 fewer falls per annum: a saving
of £275 million. As one ward manager said: if we had invented
a pill that halved the rate of falls in hospitals, why wouldn’t
we take it?BJN
Declaration: as part of the research discussed in this article, Kingston
University and St George’s, University of London funded a collaborative
research project entitled ‘Understanding the nature of leadership
© 2020 MA Healthcare Ltd
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British Journal o f Nursing , 2020, Vol 29, No 20 1205
PROFESSIONAL
behaviours that inuenced a 46% reduction the rate of patient falls in
an NHS trust by use of improvisational theatre as a research method.’
Acknowledgement: the authors would like to thank Craig Vaughan,
Brighton and Sussex University Hospitals NHS Trust, Dr Julia
Gale, Kingston University and St George’s, University of London,
Henry Larsen, Elena Strøbech, Preben Friis, Southern Denmark
University and Chris Mowles, Nick Sarra, Emma Crewe, University
of Hertfordshire for input and support to the project and subsequent
reports. The authors would also like to acknowledge the Trust’s Chief
of Safety, the late Aidan Halligan, for believing that patient falls are
preventable
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CPD reective questions
■ What is the rate of patient falls in your clinical setting, how does this
compare to the national average cited in the article, and who might you
talk to further about this?
■ What learning points can you take from this article that could help you
reduce patient falls in your clinical setting?
■ What have you learned about how staff acquire and change habits of
‘good’ and ‘poor’ practice and how might you use that learning to help
improve habits of practice in your own workplace?
■ How might you use after action reviews to address other patient safety
problems in your workplace?
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© 2020 MA Healthcare Ltd
KEY POINTS
■ It has often been assumed that falls are an unavoidable part of patients’
deterioration into frailty and are therefore inevitable
■One Trust began a project to reduce the number of patient falls, beginning
with positive role modelling in facilitating falls-safe behaviour and habits to
spread through the Trust’s ward-based teams
■The after action review process facilitated reection and feedback on
staff expectations of the outcomes of their actions leading up to the fall,
which inevitably proved conictual as staff re-negotiated their previous
assumptions about what constituted falls-safe practice and agreed what to
change
■Nurses were able to reect on a patient’s fall, work out what led to it
happening and adapt practice to their specic ward and circumstances,
leading to a reduction in falls in the Trust
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