Patient perceptions and experiences with falls during hospitalization and after discharge

Applied Nursing Research 31 (2016) 79–85 Contents lists available at ScienceDirect Applied Nursing Research journal homepage: www.elsevier.com/locate/apnr Original Article Patient perceptions and experiences with falls during hospitalization and after discharge Clayton Shuman, MSN, RN a, Jia Liu, MSN a, Mary Montie, PhD a,⁎, Jose Gabriel Galinato, MSN, RN a, Molly A Todd, MS, RN b, Marcia Hegstad, RN, MN b, Marita Titler, PhD, RN a a b University of Michigan, School of Nursing, Ann Arbor, MI 48109, USA St Joseph Mercy-Ann Arbor, Ann Arbor, MI 48106, USA a r t i c l e i n f o Article history: Received November 2015 Revised 19 January 2016 Accepted 28 January 2016 Available online xxxx Keywords: Falls Fall prevention Discharge instructions Older adults Perceptions a b s t r a c t Aims: The aim of this study was to describe hospitalized older adults' (N 60 years) perceptions about (1) their fall risks while hospitalized; (2) fall prevention interventions received while hospitalized; and (3) fall prevention discharge instructions Background: Little is known about hospitalized older adults' perceptions regarding fall prevention interventions received during hospitalization and fall prevention discharge instructions Methods: This is a prospective, exploratory study using qualitative methods Results: This paper reports qualitative findings of patients' perspectives on fall prevention interventions during hospitalization and at discharge Eight major themes supported by multiple minor themes emerged: overall perceptions of falling; overall perceptions of fall prevention interventions while hospitalized; “telling” fall prevention; “doing” fall prevention; effectiveness of fall prevention strategies; personal fall prevention strategies; fallrelated discharge instructions; and most effective fall-related discharge instructions Conclusions: Findings suggest healthcare providers need to more fully engage patients and families in understanding fall prevention interventions and factors contributing to falls during hospitalization and at discharge © 2016 Elsevier Inc All rights reserved Falls are a significant problem for older adults, particularly for those who are hospitalized (Clyburn & Heydemann, 2011; Milisen et al., 2013) Falls are among the most frequently reported patient safety incidents, accounting for approximately 40% of all adverse events in hospitals (Miake-Lye, Hempel, Ganz, & Shekelle, 2013; Oliver, 2008) Moreover, up to 50% of inpatient falls result in some sort of injury (e.g., fracture, trauma, and death) (Oliver, Healey, & Haines, 2010; Tinetti & Kumar, 2010) Falls can also contribute to patient anxiety, loss of confidence in mobility and activities, social isolation, prolonged hospital stay, discharge to long-term care facilities, and increased healthcare cost (Miake-Lye et al., 2013; Oliver, 2008; Tinetti & Kumar, 2010) Efforts to reduce falls in hospitals have largely focused on conducting routine fall risks assessments followed by implementing general fall prevention interventions for those at risk (Oliver, 2008; Oliver et al., 2010) In addition to these system- and clinician-driven efforts, fall prevention must involve other members within the context of care, including patients and their families Perceptions (e.g., beliefs and awareness) about an individual's health are essential to engage people in understanding their health risks, as well as, in adopting behaviors to reduce those risks (Garces et al., 2012; Mullins, Abdulhalim, & Lavallee, 2012; ⁎ Corresponding author at: University of Michigan, School of Nursing, 400 N Ingalls, Suite 4170, Ann Arbor, MI 48109, USA E-mail address: mmontie@med.umich.edu (M Montie) http://dx.doi.org/10.1016/j.apnr.2016.01.009 0897-1897/© 2016 Elsevier Inc All rights reserved Shubert, Smith, Prizer, & Ory, 2014) However, minimal research has addressed hospitalized older adults' perceptions about their fall risks, interventions they received to prevent falls, and discharge instructions to reduce falls Therefore, it is imperative to understand older adults' perceptions of falls and fall prevention interventions to fully engage them in the adoption of behaviors that will reduce falls during hospitalization and after discharge to more effectively address this national patient safety issue The specific aims of this exploratory study were to describe hospitalized older adults' (≥60 years) perceptions about (1) their fall risks while hospitalized; (2) interventions they received to prevent falls while hospitalized; and (3) the instructions received at discharge to prevent falls at home Background Previous studies have explored perceptions regarding falls and fall prevention, but most have focused on community-dwelling older adults rather than those who are hospitalized (Boyd & Stevens, 2009; Calhoun et al., 2011; Faes et al., 2010; Høst et al., 2011; Karlsson, Vonschewelov, Karlsson, Cöster, & Rosengen, 2013; Laing, Silver, York, & Phelan, 2011; McInnes, Seers, & Tutton, 2011; McMahon, Talley, & Wyman, 2011; Roe et al., 2009) Findings from these studies demonstrate that older adults: (1) believe falling to be a normal part of the aging process (Høst et al., 2011; McInnes et al., 2011); (2) consider falls embarrassing and have 80 C Shuman et al / Applied Nursing Research 31 (2016) 79–85 a fear of falling (Boyd & Stevens, 2009; Roe et al., 2009); and (3) restrict or stop normal activities to prevent falling (Roe et al., 2009) Findings from these studies have also been used to guide development, testing, and implementation of community-based fall prevention programs (Baker, Gottschalk, & Bianco, 2007; Tinetti et al., 2008) In contrast to findings from community settings, little is known about perceptions of hospitalized older adults regarding their fall risks, despite patient education being frequently used to prevent falls (Ang, Mordiffi, & Wong, 2011) Carroll, Dykes, and Hurley (2010) interviewed nine patients who had fallen while hospitalized and found that most were not aware of their risk of falling; those who were aware received inconsistent messages from nurses regarding their fall risks Patients stated that they “wanted to be informed of why they were at risk and what specific activities the nurse wanted them to to reduce their risk for falling, and the role of the healthcare team in their fall prevention.” (Carroll et al., 2010; page 240) Similarly, findings by Rogers (2013) demonstrated that adult inpatients had little information about their fall risks Falls are among the most frequently occurring post-discharge adverse events (Tsilimingras & Bates, 2008), and the incidence of falls in the postdischarge period is more than in the general community population (Davenport et al., 2009) The significance of discharge instruction has been demonstrated when older adults are equipped with knowledge regarding self-care following hospital discharge (Bobay, Jerofke, Weiss, & Yakusheva, 2010; Foust, Vuckovic, & Henriquez, 2012; Maloney & Weiss, 2008) However, only one study of 333 subjects, conducted in Australia, examined older adults' perceptions about fall prevention strategies after discharge and found that many had little knowledge about appropriate strategies to prevent falls at home (Hill et al., 2011) Understanding patients' perceptions about fall risks and interventions to prevent falls is critical to advance the knowledge of preventing falls during and following hospitalization This study provides insights about this important area from the perspective of the patients Method This prospective exploratory study was conducted in a 450-bed community hospital located in Michigan Informants were recruited from two adult medical–surgical units Approval of the Institutional Review Board from the University of Michigan and the study site was obtained 2.1 Design A prospective exploratory design using qualitative methods was conducted to meet the study aims To solicit participant perceptions, two semi-structured interview guides were developed with openended questions and probes The guides were designed to be delivered verbally The first interview guide was delivered face-to-face while informants were hospitalized to elicit information about their perceptions regarding falls prior to hospitalization, risk for falling in the hospital, and fall prevention interventions they received while hospitalized The second interview guide was delivered over the telephone after informants were discharged to their homes to obtain additional information about fall prevention interventions used in the hospital, and instructions that they received at discharge to prevent falls at home 2.2 Sample To be eligible for the study, potential informants had to meet the following inclusion criteria: (1) 60 years of age or older; (2) hospitalized on the study unit for at least 48 hours; (3) at risk for falls as defined by nursing staff via the Morse Score within 24 hours prior to the interview; (4) have a working phone number at home; (5) be medically stable; and (6) speak English Informants were excluded if they were acutely confused (e.g., delirious) as determined by the Confusion Assessment Method (CAM) screening tool, which was administered prior to seeking informed consent Eighteen informants were enrolled in the study, with fifteen completing the post-discharge interview We were unable to reach one informant using the telephone number they provided during the first interview; the other two were not discharged to their homes Ten informants were male, and five were female The mean age was 72 years (SD = 10.86) Informants were contacted by telephone within days after discharge to set up a time for the post-discharge interview All post-discharge interviews were conducted within days after discharge, with the majority completed within days 2.3 Data collection procedures The list of potential informants was provided by a clinical nurse specialist and nurse manager of the study units to the investigative team each day for review After validation that potential informants met study inclusion criteria, they were approached in their hospital rooms Ten eligible informants declined to participate If a potential informant was not diagnosed with delirium in accordance with the CAM, written informed consent was obtained prior to any study procedures A trained research assistant who was a part of the research team conducted inhospital and post-discharge interviews The in-hospital interview was conducted in the patient's hospital room without the presence of healthcare providers or other patients and was audio recorded During the hospital interviews, informants were asked about their perspectives concerning their risk for falling while in the hospital, and interventions they received during hospitalization to prevent falls Interviews were 45 minutes or less At the end of the interview, informants provided a home telephone number for contact following discharge After informants were discharged from the hospital, they were contacted within days via telephone to schedule an interview about their perceptions on interventions they received in the hospital to prevent falls, as well as, discharge instructions they received about prevention of falls at home All post-discharge interviews were conducted within days after discharge via telephone, were audio recorded, and lasted no more than 45 minutes 2.4 Data analysis All of the interviews were transcribed verbatim and reviewed for transcription accuracy Transcribed interviews were analyzed using the constant comparative methods of Glaser and Strauss (Corbin & Strauss, 1990; Glaser & Strauss, 1967) To ensure appropriate, rigorous, and robust data analysis, three members of the investigative team with expertise in qualitative analysis individually performed initial coding (e.g., minor themes) Minor themes were then compared, discussed, and agreed upon Individually, the three investigators organized the minor themes into major themes Major themes were then compared and discussed until a consensus was reached Results Qualitative data analysis revealed eight major themes: (1) overall perceptions of falling; (2) overall perceptions of fall prevention interventions while hospitalized; (3) “telling” fall prevention; (4) “doing” fall prevention; (5) effectiveness of fall prevention strategies; (6) personal fall prevention strategies; (7) fall-related discharge instructions; and (8) most effective fall-related discharge instructions Multiple minor themes support each of these major themes, and are discussed below 3.1 Overall perceptions of falling The major theme, overall perceptions of falling, is supported by three minor themes, including past fall experiences, fall risks, and fear of fallrelated injuries C Shuman et al / Applied Nursing Research 31 (2016) 79–85 3.1.1 Past fall experiences Most informants perceived that they had indeed experienced one or more falls prior to their current hospitalization Not only did informants experience one or more falls, but that they also perceived the reasons for these falls: 81 3.2.2 Tailored fall prevention interventions A number of informants shared that the fall prevention strategies they received during hospitalization were specific to their healthcare needs: “…Well, I think they were designed specifically for my problems, which was herniated discs, and the surgery that I had…” “…Because I have a lack of balance…I lost balance…” “…Dehydration and low blood pressure…” Other reasons noted by informants that contributed to their falls included other health conditions (e.g brain tumor, herniated disc), not paying attention to their surroundings, and medications they were taking 3.1.2 Fall risks It is noteworthy that despite being currently designated as fall risks by healthcare providers, as well as having experienced prior falls, most informants stated that they did not believe they were at risk for falling while in the hospital: “…No, because there is enough people around when I get up go to the bathroom They all helped me…” “…I′m not necessarily concerned about falling because the hospital staff…they have a belt on me So, I′m not worried about that…” The majority of the informants felt safe due to the presence of healthcare providers and the healthcare they received, which led them to trust their healthcare providers (e.g., nurses) 3.1.3 Fear of fall-related injuries Despite the apparent trust the informants had with their healthcare providers, they were concerned about potential injuries that could result from a fall while they were hospitalized: “…I guess break a bone I have osteoporosis…” “…That I will break hip and be in the hospital as I were in the midst of having the cancer, and I live alone, so it′s very hard for me…” As in other issues with the elderly, their fear of falling is one of several issues that is compounded by other health conditions and living arrangements experienced by older adults 3.2 Overall perceptions of fall prevention interventions while hospitalized Interviews conducted during and after discharge asked the informants to share their perceptions about what was done to prevent falls while they were hospitalized These interviews resulted in four minor themes, described below, to support this major theme, overall perceptions of fall prevention interventions while hospitalized “I would say the reminder [was specific to me], like I am a bare-footed person all the time around the house and everything, a reminder of putting socks on every time I got up was beneficial to me…” 3.2.3 General fall prevention interventions Other informants, however, perceived that all patients received the same general fall prevention interventions: “Yes, I think they [all patients] were told the same things…” “I don′t think they [fall prevention strategies] were specifically for me, they were pretty general…” 3.2.4 Overall satisfaction of fall prevention interventions Informants shared thoughts on whether their healthcare providers could have contributed more to their fall prevention: “…No, they are pretty thorough Yeah, they are pretty much focusing on your problems and your situation, and try to give you the best…” “…I′m pretty sure that the people that [are] working in the hospital are pretty good at instructing their patients And I know me and probably a lot of other patients tend to be a little stubborn, or we press the call button, and they′re busy, and they can′t come right away, so we decide to get up and try something on our own…” Although informants initially expressed that they did not receive information to prevent falls while they were hospitalized, as the interviews proceeded, and with use of interview probes, informants were able to give examples of healthcare providers' actions that were utilized to prevent them from falling Some informants thought the interventions were specific to their needs, while others thought the interventions were more general and the same for all patients The kinds of fall prevention interventions that were received during hospitalization are further described in the following two major themes: “telling” fall prevention and “doing” fall prevention 3.3 “Telling” fall prevention Informants described what their healthcare providers were “telling” them in regard to how they could reduce their risk of falling while hospitalized They discussed three fall prevention areas: (1) reminders; (2) clearing obstacles; and (3) general assistance 3.2.1 Non-acknowledgement of fall prevention interventions Initially, informants stated that healthcare providers had not had conversations with them about falls: 3.3.1 Reminders Informants stated that their healthcare providers discussed some general reminders in regard to fall prevention: “I don′t think they′ve talked about falling, but they′ve taught [me] how to get into the bed and out of the bed They trained me how to it, which I assume is to prevent falling…” “They said not get up by myself…They just say go slow and made sure that at least one of them [nurse] is in the room, and they took good care of me…” “…Always reminding me to put my slippers on, or my socks on.” “…Uh, I don′t know if they have actually told me anything about falling.” However, as the conversation proceeded, informants started discussing fall prevention interventions performed by healthcare providers and their satisfaction with these interventions 3.3.2 Clearing obstacles Informants explained that their healthcare providers had also engaged them in conversations about clearing obstacles: 82 C Shuman et al / Applied Nursing Research 31 (2016) 79–85 “…[They make sure the] floor is clear of obstacles, and they make sure that, if you have any cause for them [obstacles] to think you might fall, they won′t let you move, unless there′s somebody with you…” “…obstacles that may, you know, be in your way, remove them or slide them over from where your walking path would be ” to make sure that there′s help available very quickly as you need it…” In many cases, informants' personal perceptions of the most effective fall prevention strategies were the same strategies that had been provided by healthcare providers in the hospital 3.6 Personal fall prevention strategies 3.3.3 General assistance Informants also described general assistance that was inclusive of fall prevention For example, they commented on assistance with ambulation and mobility: “Well they told him all those techniques…how to get into the bed and not fall back…or how to hold on to the walker How to turn, not twist All of the things that you need to know in order to successfully move around without damaging yourself” “…I know this afternoon, they want to put me in a chair, and that I will be getting a lot of help for that…” 3.4 “Doing” fall prevention After informants clarified what healthcare providers were “telling” them about fall prevention while they were hospitalized, they then discussed what their healthcare providers were “doing” with regard to fall prevention Informants indicated that healthcare providers were “doing” several things, such as teaching fall prevention and providing physical assistance 3.4.1 Teaching Informants explained that their healthcare providers gave them a great deal of instruction regarding fall prevention: “…They teach me move slowly, you can raise up, and so I get my chest up and swing my feet a little bit slowly…” Patients' perceptions about ways to reduce their own risk of falling are important, since they depict how patients view themselves as at risk for falls The study informants remarked that they thought becoming more proactive and acquiring better awareness of their surroundings would assist them in reducing their own risks for falls 3.6.1 Being proactive Informants stated that one way in which they thought they could lessen their fall risks was by becoming more proactive, by paying more attention to their fall risks, and by following the advice of their healthcare providers: “…Uh, probably the biggest thing would be to pay attention…And understand the seriousness of it [falling]…” “…I think people have to be better judges of what they can really do…” 3.6.2 Acquiring awareness of surroundings Informants also stated that another way to reduce their risks for falling was to become more aware of their surroundings: “…I can see certain things, like design of furniture, design of doorways, design of height of furniture…I feel a lot of attention should be applied for older people…” “…if you got throw rugs, you don′t want those around because you could stumble over them.” “Well, they teach me how to stand and lean…Just get my balance, so I don′t fall And they give me a lot of support and encouragement…” 3.7 Fall-related discharge instructions 3.4.2 Physical assistance Informants also indicated that they received physical assistance for fall prevention This included a variety of activities, such as assistance with mobility (e.g., utilization of a walker), belt security, and chair/sitting assistance During the post-discharge interviews, informants shared information they received at discharge that focused on preventing falls at home This major theme, fall-related discharge instructions, is supported by two minor themes described below “…Well, when I walked, they had a belt around me, and somebody back of me, following along, with a grip of the belt…” 3.7.1 Initial perceptions of fall-related discharge instructions Informants discussed discharge directions, specifically with regard to fall prevention: “…Well, they′ve been very kind about lifting me out of the chair on the commode, and rolling me in there, rolling me up to the sink, so I can wash my face.” “…There wasn′t any discussion of that… You know frankly, I didn′t think about that.” “I don′t believe I was told anything.” 3.5 Effectiveness of fall prevention strategies Informants went on to share their perceptions about the effectiveness of the fall prevention interventions on the basis of their personal conditions and own experiences “I guess my walker will be the most effective…” “Well, I think they make sure that in the room or wherever I am, that there are as few obstacles as possible And that they try Over half of the informants did not initially perceive that they had received discharge instructions about fall prevention However, further interview probes with these informants revealed that they had indeed received discharge instructions regarding fall prevention 3.7.2 Verbal and written discharge instructions Informants elaborated that healthcare providers not only verbally delivered fall prevention instructions about the physical environment and mobility, but also provided a fall prevention pamphlet and other written information C Shuman et al / Applied Nursing Research 31 (2016) 79–85 83 3.7.3 Physical environment Informants stated that conversations at discharge included specific fall prevention concerning physical environment: “…Clear the area of debris…And um keep everything organized and structured and you′d have no problems of walking around…” “I was interviewed by the case manager, and she was very interested in the layout of my home, as far as entrances, exits, um that had something to with falling…” “…Watch out for area rugs that are sticking out the corner Either nail them down or remove them from the room, if it′s an area rug that has tilted upwards…” “…In the bathroom, always have a rubber mat in the tub, and some rug that′s for a bathtub, water resistant, a rug outside of the tub, so when you step out, your risk for falling would be reduced by that too…” Informants acknowledged that the fall prevention instructions they received at discharge addressed both physical and environmental effects Informants were eager to discuss these fall prevention strategies, and most informants stated that the information they had received regarding fall prevention was helpful 3.7.4 Mobility Mobility discussions were also expressed by the informants: “…They went through a lot of suggestions…They′ve offered a pretend car and they showed you ways to get in and out…” “…First of all, I′m not supposed to make fast moves, fast turns, sharp turns I was supposed to move very slowly I was not supposed to it on my own I should be using a walker or be with someone…” 3.7.5 Written discharge instructions Informants shared that they also received written information (e.g., pamphlets) regarding fall prevention: “…There were sheets, there were copies that were given me to discuss some of this stuff [fall prevention]…” “…They gave me, you know, a lot of, you know, books and pamphlets, and lists and that And that was very, very helpful…” Although informants initially responded that they had not received discharge instructions, they were able to share that they did receive both verbal and written information about prevention of falls at home Informants also shared their perceptions about the effectiveness of the discharge instructions as described below 3.8 Most effective fall-related discharge instructions According to informants, the most effective fall prevention instructions included both physical and environmental strategies 3.8.1 “Physical” fall preventions Informants discussed several fall prevention instructions that aided them physically: “The three-point stance I always have three points of… before you move, get balance as much as possible, don′t try to stretch out, or reach, or more than you can…” “You know they taught you how to sit up They said don′t twist, or roll Just getting yourself in a sitting position those few days after surgery was work And they were very helpful with that…” Informants reported not only that they received adequate instruction, but also that they were “shown” how to physically prevent falls 3.8.2 “Environmental” fall preventions Informants also stated the fall prevention instructions at hospital discharge included environmental advice: Discussion Findings from this exploratory study revealed that most informants had fallen one or more times prior to hospitalization, and that most knew what had contributed to their falling (e.g., loss of balance) These reasons suggest a similarity to other studies that have reported balance as a contributing factor for falls in older adults (Carroll et al., 2010; Huang et al., 2012; Talbot, Musiol, Witham, & Metter, 2005; Zecevic, Salmoni, Speechley, & Vandervoort, 2006) Despite acknowledgement of experiencing a fall, informants were not aware that they were at risk for falls while hospitalized Informants did, however, freely express their fear of falling and potential injuries (e.g., broken bone, broken hip) while they were hospitalized These findings are similar to other studies in which patients have a fear of falling during hospitalization because they are frail and have poor functional reserve (Mackintosh, Hill, Dodd, Goldie, & Culham, 2006; Oliver et al., 2010) Although informants did indeed receive fall prevention interventions while hospitalized, they initially did not perceive these interventions as such After further discussion (e.g., probing), informants commented on various conversations and actions that their healthcare providers initiated regarding fall prevention Examples include what their healthcare providers were “telling” them (e.g., reminders, clearing obstacles, and general assistance), and what healthcare providers were “doing” to assist them (e.g., teaching and physical assistance) In subsequent conversations, informants stated that they were not only satisfied with these fall prevention interventions (e.g., “…they were very thorough” and “…are pretty good at instructing patients…”), but also that some felt they received fall prevention interventions tailored to them (e.g., “…designed specifically for me…”) The acknowledgement of tailored fall prevention interventions is congruent with recommendations that these interventions should be tailored to patient-specific fall risk factors (Cameron et al., 2012; Coussement et al., 2008; Hempel et al., 2013; Kenny et al., 2011; Oliver et al., 2010) Informants felt that these actions (e.g., fall prevention interventions) were effective Likewise, informants did not initially perceive that they had received fall prevention interventions at discharge After further probing, informants reported that they had not only received verbal discharge fall prevention instructions with regard to the physical environment and mobility, but they had also received written information about preventing falls (e.g., sheets, books, and pamphlets) In addition, informants discussed their perceptions regarding the most effective fall prevention discharge instructions that they received These perceptions included both physical (e.g., three-point stance and body positioning), and environmental strategies (e.g., clearing areas of debris and rug placement) These perceptions parallel the work of Hill et al (2011), as these strategies were also identified by patients as post-discharge fall prevention strategies It is important to note that informants initially did not perceive that they were at risk for falls or received interventions to prevent falls during hospitalization and at discharge However with further probing, and as the interviews progressed, the informants clarified their perceptions and described fall prevention interventions they received These initial 84 C Shuman et al / Applied Nursing Research 31 (2016) 79–85 perceptions by informants suggest that patients may not be mindful of their risk for falls, and perceive that the healthcare team will keep them safe Additionally, these initial perceptions about their fall risks and interventions they received to prevent falls suggest that healthcare providers' level and type of engagement with patients and families regarding understanding their fall risks, and interventions to prevent falls has significant room for improvement 4.1 Limitations Our study consisted of a single hospital setting, which only accounts for patients' perspectives from that site Although findings may not be generalizable beyond the current setting, we acknowledge the value of replicating this study at multiple sites, since patient perceptions of fall interventions are important for fall prevention Further research is needed in multiple sites to support these findings 4.2 Implications for research This study should be replicated as a multi-site study representing different geographic regions of the country Future research should also include interviews of family members in addition to patients, as well as the healthcare providers delivering care Preventing falls in hospitals is a collaborative mission that requires the participation of patients and family members Thus, further research is needed to understand how healthcare providers can more effectively engage patients and family members in prevention of falls during hospitalization and following discharge 4.3 Implications for clinical practice There are several implications for practice from this study First, nurses and other healthcare providers in hospital settings need to more than impart information, but rather have conversations with hospitalized patients and their families about why they are at risk for falling, and define the specific fall risk factors they have that may contribute to a fall or injury from a fall Second, having repeated conversations with patients and family members about what they can contribute (e.g., paying more attention; heeding advice of the healthcare team) to prevent falls is also warranted Lastly, nurses should explain to patients and family members that fall prevention is a collaborative process, which necessitates the active participation of patients and their family members in understanding their risks for falling and interventions to prevent falling Conclusion This exploratory study revealed that informants received fall 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