The results of this study showed a mean score of 48.9 for the knowledge of falls, which is lower than the score of 6.84 out of 14 items reported in a previous study [22, 23] measuring knowledge regarding falls among university hospital nurses and a score of 66 reported in another study of nurses in general hospitals . These findings suggest that nurses at small and medium-sized hospitals’ knowledge regarding falls is lower than that of nurses at tertiary care hospitals. Perhaps this is because small and medium-sized hospitals offer fewer educational opportunities compared to tertiary care hospitals, which provide consistent patient safety education. The item with the lowest knowledge score regarding falls pertained to consciousness at the time of a fall, followed by those pertaining to frequent diseases that cause falls and bodily injury resulting from falls; these findings were similar to those of previous studies . Fall-prevention methods were the most frequently reported educational content that nurses in the study experienced; however, educational content reviewing the causes and effects of falls should be increased in fall-related education.
Levels of knowledge regarding falls in participants who had experience of patients falling were significantly higher relative to those in participants who had no experience of patients falling. This finding is consistent with those of a previous study  that measured knowledge regarding falls in university hospital nurses and showed that participants’ knowledge regarding falls increased as their interest in falls increased, once they had experienced patients falling.
Mean score for the positivity of nurses’ attitudes regarding falls was higher relative to the scores reported in previous studies using the same questionnaire [19, 22, 24]. The positivity of nurses’ attitudes regarding falls could have increased as the importance of patient safety increased because of small and medium-sized hospitals’ voluntary participation in the medical institution accreditation system introduced through an amendment to the medical law in June 2010.
Attitudes regarding falls varied depending on the duration of work experience. The positivity of attitudes regarding falls in nurses who had worked for over 5 years was higher than reported by the nurses who had worked for less than 5 years. This finding is consistent with previous research reporting significant differences in attitudes based on length of nursing career [22, 24]. This finding might be the result of the higher level of responsibilities and sense of duty found in experienced nurses. Less experienced nurses typically are focused on general nursing activities rather than those involving patient safety.
Participants’ mean score for engagement in fall-prevention activities was higher relative to the score of 81.5 previously reported in a study of nurses at a general hospital  and the score of 77.3 reported in a study of nurses at small and medium-sized hospitals , but was lower relative to the score of 89.8 reported in a study of nurses in geriatric hospitals . The lowest scores were given to Item 18 (e.g., providing a non-slip mat when patients take a barrel bath or shower) and Item 3 (e.g., reassessing fall risk factors after admission). This was consistent with the findings of a study of nurses in a general hospital . It could have been difficult for nurses to reassess fall risk repeatedly and perform fall-related nursing duties regularly in small and medium-sized hospitals, which have less staff performing fall-prevention duties and patient assessments, relative to those at tertiary care hospitals. Aggressive fall-prevention activities require standardized environmental assessment tools for fall risk, and the installation of preventive environmental facilities tailored to small and medium-sized hospitals is needed.
Nurses’ attitudes regarding falls were more positive the greater number of fall-prevention education sessions they attended. Therefore, we suggest that regular and recurrent fall-prevention education targeted to small and medium-sized hospitals would reinforce and improve nurses’ attitudes toward patient falls.
Attitudes regarding falls were significantly positively correlated with engagement in fall-prevention activities; however, we found no relationship between nurses’ knowledge regarding and their attitudes regarding falls or engagement in fall-prevention activities. These findings are consistent with previous research [19, 22, 25]. For example, a multifaceted strategy, including reminders and identification systems, audits and feedback, and further education, has been found to effectively increase fall-prevention activities . Engagement in fall-prevention activities should be increased via attitude reinforcement programs for nurses.
We observed few significant differences in knowledge or attitudes regarding falls and no significant differences in engagement in fall-prevention activities according to participants’ characteristics. This finding might be explained by career nurses’ mannerisms resulting from dissatisfaction with their work environments— small and medium-sized hospitals see high nurse turnover and often have insufficient workforces to meet their operational needs . Patient safety activities in small and medium-sized hospitals should be enhanced by creating an atmosphere to foster voluntary and self-directed engagement in fall-prevention activities through the use of motivation and rewards.
The findings described above indicate that consistent and recurrent fall-prevention education tailored to small and medium-sized hospitals should be implemented to promote engagement in fall-prevention activities. In addition, the positivity of nurses’ attitudes regarding falls was an important factor affecting behavioral intention, and the promotion of changes in attitudes regarding falls via introducing attitude-reinforcement programs that consider nurses’ subjective norms must enhance their sense of responsibility and duty.