Daily work variability in falls prevention of hospitalized patients: Nursing team’s perception

doi:10.21203/rs.3.rs-2085321/v1

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Daily work variability in falls prevention of hospitalized patients: Nursing team’s perception

https://doi.org/10.21203/rs.3.rs-2085321/v1

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published 31 Aug, 2023

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Background: the identification of safety incidents and establishment of systematic methodologies in health services to reduce risks and provide quality care was implemented by The World Health Organization. These safety incidents allowed the visualization of a wide panorama, ranging from preventable incidents to adverse events with catastrophic outcomes for patients. In this scenario, the issue of fall(s) is inserted, which, despite being a preventable event, can lead to several consequences for the patient, family and the healthcare system, being the second cause of death by accidental injury worldwide, this study aims to identify the variability inherent in the daily work in fall prevention, the strategies used by professionals to deal with it and the opportunities for improvement of the management of work-as-imagined.

Design: an exploratory and descriptive study, of qualitative approach, through process modeling and semi-structured interviews.

Methods: was conducted in a public university hospital in southern Brazil, following four steps: modeling of the prescribed work; identification of falls; modeling of the daily work and reflections on the gap between work-as-done and work-as-imagined. Medical records, management reports, notification records, protocols, and care procedures were consulted for modeling the work process and semi-structured interviews were conducted with 21 Nursing professionals. The study was conducted between March 2019 and December 2020.

Findings: from July 2018 to July 2019, 447 falls occurred, 2.7% with moderate to severe injury. The variability occurred in the orientation of the companion and in the assurance of the accompanied patient's de-ambulation. The professionals identified individual strategies to prevent falls, the importance of multi-professional work, learning with the work team, the colleague’s expertise, as well as suggesting improvements in the physical environment.

Conclusion: this study addressed the need for fall prevention in the hospital setting as one of the main adverse events that affect patients. The identification of the variability inherent to the work allows professionals to identify opportunities for improvement, understand the risks to which patients are subjected and develop the perception of fall risk as a way to reduce the gap between work-as-imagined and work-as-done.

Nursing

Accidental Falls

Patient Safety

Workflow

Complexity

Socio-technical systems

A fall is defined by the unintentional displacement of the body to a level below the initial position without the possibility of timely correction, compromising stability and aggregating a multitude of associated factors (World Health Organization, 2008, Severo et al., 2018). It is an occurrence related to care rather than the underlying disease, which prolongs the patient's length of stay or results in a disability to the point of discharge (World Health Organization, 2008).

This is an unwanted situation that breaks with the quality of care, exposing healthcare institutions and their professionals. In addition, falls increase hospital costs (Gu et al., 2016), length of hospital stay, and predispose to other falls due to the patient's fear of falling again (Severo et al., 2014), Barbosa et al., 2019)

Falls represent a public health problem worldwide, being considered the second leading cause of death by accidental injury, with age as the main risk factor (World Health Organization, 2008). Thus, they represent a challenge to the professionals who care directly to the patients, to the leaders who manage this care, and to the organizations.

The planning of resources, both personnel and equipment, tends to mitigate the risks to which patients are exposed. This strategy requires engagement of professionals, focus on the work process, and individual patient-oriented orientation in view of the professionals' knowledge of the patients' profile (Barbosa et al., 2019).

Identifying the risk factors for falls is clearly the first and most important step in the whole process to prevent falling (Barbosa et al., 2019), reinforcing the need for healthcare professionals to know predictive factors, in addition to the criteria for identifying and assessing patients through the risk prediction models (Severo et al., 2014).

Despite the prediction models helping in the identification of patients with higher risk of falling, there may be, on the part of the professional and the patient himself, a mismatch between the perceived risk of falls and the real risk, as well as in the measurement of this risk. Faced with the complexity of the outcome, the execution of the prescribed work does not always occur as planned (Heng et al., 2020).

In the gap between work-as-imagined (WAI) and work-as-done (WAD), there is great potential for variability represented by falls, facts that are justified by the presence of independent agents who act without the understanding of the whole, agents who adapt based on their experiences and due to the self-organization of systems, making it more likely to influence the behavior of the system than to control it (Lipsitz, 2012). Furthermore, these characteristics reinforce the hospital institutions as Complex Sociotechnical Systems (CCS) in which the interaction of these elements does not present linearity, causing that small changes in the work processes may cause disproportionate results (Righi & Saurin, 2015).

In CSS, such as hospital settings, it is important that the understanding of the gap between WAI, such as care protocols and standard operating procedures, and the work that occurs in practice (real work) be analyzed to identify future interventions aimed at improving patient safety and quality of care by bringing WAI closer to WAD (Ashour et al., 2021).

In order to understand the gap between WAI and WAD, the Functional Resonance Analysis Method (FRAM) was created, a Resilience Engineering tool that makes it possible to analyze the variables of a work process that can interfere with the outcome of an event (Hollnagel, 2018). Focused on understanding the impact of this variability, this tool allows work processes to be reconstructed, through modeling, comparing planned work with executed work. The study aims to identify the variability inherent in the daily work in fall prevention, the strategies used by professionals to deal with it and the opportunities for improvement of the management of work-as-imagined.

2.1 Patient Safety and the Fall

The patient safety is defined as the reduction, to the minimum acceptable, of the risk of unnecessary harm during health care (World Health Organization, 2009). Although unsafe acts in health could occur on a large scale, it was in the 90's, in a publication by the Institute of Medicine, that the issue of patient (in)safety gained worldwide repercussion through the disclosure of incidents that affected patients within health institutions. Since then, patient's safety started to be treated with relevance and institutions have been showing more and more concern with their events and rethinking ways to work with them (Institute of Medicine (US) et al., 2000)

The World Health Organization, by identifying these safety incidents, has established systematic methodologies in health services to reduce risks and provide quality care. The identification of safety incidents allowed the visualization of a wide panorama, ranging from preventable incidents to adverse events with catastrophic outcomes, such as death, for patients. In this scenario, the issue of fall(s) is inserted, which, despite being a preventable event, can lead to several consequences for the patient, family and the healthcare system, being the second cause of death by accidental injury worldwide (World Health Organization, 2020).

The identification of risk factors for falls in hospitalized patients facilitates a more accurate measurement of the risk of falling and has a positive impact on patient safety (Severo et al., 2018). The predictive risk factors for the event can be classified into intrinsic (patient-related) and/or extrinsic (environment- and work-related) (Severo et al., 2014; Severo et al., 2018).

Among the intrinsic risk factors, disorientation/confusion, sleepiness, dizziness, agitation, hallucinations, delirium, cognitive impairment, age extremes, impaired mobility and balance, altered visual acuity, frequent urination and/or diarrhea, history of falls, comorbidities, and medication effects stand out. The extrinsic risk factors related to the environment are slippery floors, inadequate lighting, excessive furniture, among others, as well as work process factors such as the number of patients/nurses, high work demand, absence of a caregiver at the time of a fall, typology of units such as orthopedic, neurological and psychiatric units, response time of the bell and peak hours of activities (Severo et al., 2014; Barbosa et al., 2019).

Therefore, identifying the risk factors for falls is clearly the first and most important step of the whole process (Barbosa et al., 2019), reinforcing the need for healthcare professionals to know these predictors, in addition to the criteria for identifying and assessing them in patients through risk prediction models (Severo et al., 2014).

The next step after the identification of risk factors is the implementation of measures to minimize the possibility of falls, through protocols or SOPs (Standard Operational Procedure), followed by improvements in communication between different professionals of the team, who are in charge of the patient's hospitalization, as well as the continuous strengthening of the safety culture of an institution with the adaptation of specific needs (Gu et al., 2016). Although SOPs are based on the identification of common factors for patients and show success in their implementation, it is necessary that risks are individualized, using information technology and tools (Kafantogia et al., 2017) as a means to bring the WAI closer to the WAD.

Thus, in addition to prediction scales and SOPs, the identification of the role of the direct caregiver, represented by the nursing technician, the care administrator, in the figure of the nurse, and the decisions focused individually on the patient and their family (constituted by the multi-professional team) place a fall assessment and prevention program at the forefront of a hospital institution (Kafantogia et al., 2017; Kenny et al., 2017).

2.2 FRAM as a method to analyze the variability of daily work

There is a noticeable distinction between the items that are part of WAI in the form of protocols, procedures (WAI) and the way the work is conceived in daily practice (WAD) (Clay-Williams et al., 2015). In this sense, the gap that arises between the WAI and WAD can be explained by a variability of factors ranging from a need to set priorities within an environment with high complexity by an unfavorable work environment and even by human conditions (Hollnagel, 2018).

The search for the reduction of the WAI/WAD gap stimulates the development of actions, making health institutions establish quality and safety standards, minimizing errors and working with predetermined standards in order to achieve international patient safety goals, specifically in this context, reducing the variability that predisposes to the instances represented by the falls (Joint Commission International, 2021).

The concept of WAD and WAI presented so far has, as its theoretical basis, Resilience Engineering (RE). The RE emerges as a paradigm for security management, especially for CSS, which seeks to measure, assess, and improve the resilience of a system (Hollnagel et al., 2006). From the RE perspective, the resilience of a system is defined as "the intrinsic ability of a system to adapt its functioning, before, during, or after some change or disorder, in order to maintain necessary operations under expected and unexpected conditions" (HOLLNAGEL, 2011, p. XXXVI). Under the same optics of RE, the Functional Resonance Analysis Method (FRAM) arises.

FRAM is a method used to describe the activities of CSS, capturing the variability (actual or potential) of the daily work. FRAM is based on four principles: (i) equivalence - indicates that both success and failure arise from the same processes; (ii) adjustment in performance - people continually adjust to account for the contextual conditions at that given time; (iii) emergent phenomena - outcomes, in SSC, cannot be explained with a linear cause-and-effect relationship; (iv) functional resonance - can be used to understand interaction and non-linear outcomes (Hollnagel, 2018).

FRAM identifies and describes the main functions of the analyzed system, considering its potential (or real) variability. For each function identified in the system, the following aspects can be described: (a) Input - activates or initiates the function; (b) Output - result of the function; (c) Precondition - state or conditions to initiate the function; (d) Resource - required or consumed during the realization of the function; (e) Time - temporal characteristic of the function; (f) Control - supervises or regulates the function (Hollnagel, 2018). The different functions interact with each other through couplings (Figure 1), when an output of one function is an input, precondition, resource, time, or control of another. And it is in this coupling that the variability of the output of a function ends up impacting the performance of the functions coupled to it.

Figure 1 represents a cutout of the process of measures to prevent falls in adult inpatients and highlights the coupling of the functions <attend to the use of drugs that alter sensory and muscle strength>, <identify risk>, and <put on bracelet>. The variability, represented by a symbol similar to a sine (or wave), in the output of the function <attempt to use drugs that alter sensory and muscle strength>, in terms of precision (e.g., not perceiving possible alteration of sensory) or in terms of time (e.g., perceiving it too late), has repercussions on the triggering of the functions coupled to it downstream. These functions are critical in the process of preventing falls.

FRAM has been gaining space for the analysis of CSS such as health services. The use of FRAM in healthcare has been applied, for example, in the studies (i) of Wachs & Saurin (2018), evaluating the medication process in an emergency department; (ii) of Rosso & Saurin (2018), analyzing the flow of the critically ill patient between the emergency department and the Intensive Care Unit; (iii) of Clay-Williams et al., (2015) to understand WAD and approximate WAI to that performed during the process of guideline implementation in ICUs (iv) of Damoiseaux-Volman et al., (2021), which used FRAM to demonstrate the difference between WAI and WAD in relation to falls and delirium; and of Quadros et al. (2022), which is part of the same research project as this study, analyzing falls of adults hospitalized patients and their repercussions on Nursing worker as a second victim.

3.1 Aims

This study aims to identify the variability inherent in the daily work in fall prevention, the strategies used by professionals to deal with it and the opportunities for improvement of the management of work-as-imagined. The research question was: i) what is the variability (WAI/WAD gap) of the activities involved in the occurrence of fall(s) in adult hospitalized patients?

3.2 Design

This is an exploratory and descriptive study, of a qualitative approach. Qualitative research uses a set of analysis techniques in order to obtain, through systematic procedures, the content of the messages of the subjects that allow the inference of knowledge related to the conditions of production/reception of the messages (Bardin, 2011).

The study was conducted in a public, general and university hospital, with a capacity of 843 beds. This hospital is located in the South of Brazil and is considered a reference center for assistance, professional training, and knowledge generation. It has an occupancy rate of 125,396 patients/day, 42,847 surgeries/year, and 12,786 hospitalizations/year.

With specific regard to incidents involving patient’s fall, since 2012, the institution has had a Multi-professional Commission on Falls under the coordination of two nurses. The committee meets weekly with representatives from all services of the institution, analyzes the occurrence of falls, proposes improvements, and monitors, through indicators, the rates of falls in the institution.

3.3 Steps of the study

Figure 2 shows the steps taken to develop this study: modeling (WAI); identifying falls; modeling daily work (instantiations of the identified falls) (WAD) and, finally, reflections on the gap between WAI and WAD.

3.3.1 Step 1 - Modeling the work-as-imagined

The first stage proposes to portray the work-as-imagined.

3.3.2 Data collection

To do so, data were collected from the care protocol for falls in adults and the SOP for measures to prevent falls in hospitalized adult patients.

3.3.3 Data analysis

The content analysis of the documents contemplated the steps proposed by Handbook for FRAM modeling (Hollnagel, 2018) : (i) identify and describe the main functions (and aspects) of the system; (ii) characterize the potential variability of each function; (iii) aggregate the variability (couplings). The data was analyzed using the FRAM Model Visualizer Software.

3.4 Step 2 - Identification of falls

For the identification of falls, the population was composed of the total of hospitalized adult patients who had a fall (N=447) stratified into clinical and surgical inpatient units (N=242). The sample was made up of patients who had moderate harm to death (N=12). Patients who had moderate to fatal falls represent a smaller number, however, it is possible to extrapolate the analysis for falls without injury to mild injury, since they occur in the same way, although with less repercussion to the patients.

3.4.1 Data collection

Data collection for the identification of falls was performed in medical records, notifications, and investigations report and management data.

3.4.2 Data analysis

Analysis of the data allowed the severity of the damage to be identified, constituting the second stage of the study. The period consulted was from July 2018 to July 2019.

3.5 Step 3 - Modeling the daily work

To perform this step, the data collected and analyzed in the previous steps were considered. Thus, the third step consisted in modeling the real work (falls identified in the previous step), considering the instantiations of daily work.

3.5.1 Data collection

The data sources were the Management Information System, the Strategic and Operational Management System, and information from medical records.

3.5.2 Data analysis

For such modeling, we took, as a starting point, the modeling of the prescribed work, identifying the variability that occurred in the roles and the new roles that emerged from the event.

3.6 Step 4 - Reflection on the gap between WAI and WAD

Nursing professionals who worked in inpatient units were the population of this stage of the study, totaling 153 professionals (N=153). The sample was formed by random drawing among those who worked in the units and in the shifts in which the falls occurred. To maintain anonymity, the participants were coded as NURS for nurse and NT for nursing technician, adding the number of the interview. They were asked to identify the care prescribed and how the work occurred on a daily basis to implement the protocol that identifies the risk of the patient falling.

3.6.1 Data collection

Data was collected using a semi-structured interview technique with an average duration of 35 minutes. For each shift in which a fall had occurred, one nurse and two nursing technicians were chosen. The interviews were closed when data saturation occurred, and the sample consisted of 21 nursing professionals (N=21).

Data collection began with the presentation of the study and the reading of the Participant Informed Consent (PIC). After consent, the participant was contextualized about the previous stages of the study, through a modeled event, the use of the modeling tool (FRAM), the variability that occurred and its implications on quality of care. The interview script had as main questions: what are the difficulties identified by the professional for the patient to adhere to the institutional protocol? How is it possible to minimize the occurrence of the event?

3.6.2 Data analysis

Data analysis was performed using the Content Analysis technique, following the systematic three phases: pre-analysis, material exploration and treatment of results, inference and interpretation (Bardin, 2011). The analysis procedures aim to explore the manifest content of the messages so that it is possible to identify the units of record, which were coded and classified so that they can answer the guiding questions raised in the interviews.

3.7 Ethical considerations

This research was registered in Plataforma Brasil under CAEE no. 35069714.7.0000.5327 and approved by the Research Ethics Committee (REC) under Opinion no. 2.554.758. The researchers committed to maintain the secrecy and confidentiality of information at all stages, meeting the aspects contemplated in Resolution No. 466/12 of the National Research Ethics Committee (Brasil, 2012). For the use of the hospital databases, a Term of Commitment for the Use of Institutional Data was filled out, ensuring the use of the information collected for research purposes only. The participants of the interview were given the PIC. The speeches were recorded on digital audio, later transcribed without the use of software and kept under the custody of the principal researcher for five years as recommended by the National Research Ethics Council (CONEP) (Brasil, 2012).

3.8 Rigour

The guarantee of methodological rigor in qualitative research occurs through the path chosen by the authors in which they can justify the decisions made and ensure that the data collection procedures and the instruments used guarantee the ethics and transparency necessary for research. This care enables the results of a qualitative study to have internal and external consistency, ensuring the reliability of the analyses performed (Peter, 2015; Minayo & Guerriero, 2014).

To ensure credibility, reliability, and findings in the design of this study, a validation of the results found in the prescribed process modeling step was performed through an interview with the professionals. Prior to data collection, a pilot interview was conducted with a professional who was not part of the study as a way to calibrate the sequence of questioning. The principal investigator held frequent meetings with members of the research team, who have expertise in the field, which enabled a consensus regarding the interpretation and categorization of the data. In addition, the principal investigator is a nurse with experience in the work processes of the study's focus institution and in conducting semi-structured interviews.

To ensure transparency, the recommendations of the Consolidated Criteria for Reporting Qualitative Research (COREQ) were followed (Souza et al., 2021).

4.1 Step 1 - Modeling the work-as-imagined

From the care protocol for falls in adults and the SOP for measures to prevent falls in adult inpatients, it was possible to model the prescribed process. The prescribed process was modeled with the help of a software called FRAM Model Visualizer and is represented in figure 3.

A total of 22 functions related to the process of preventing falls in adult inpatients were identified. The functions represented in yellow indicate functions that initiate the modeling. The seven functions that initiate the modeling (in yellow) may occur in different moments: when the patient is admitted; when receiving the patient after the surgical procedure; when noticing a change in the patient's general state; when performing the assessment after the patient falls or slips; when applying the assessment tool for fall risk (weekly) and contemplating some comorbidities of the patients that lead to individual risks of falling, such as the risk of bleeding and the use of drugs that alter the sensory and muscle strength.

From the function that identifies the risk (<identify risk>) and visually signals the professionals (<put on bracelet>), five other functions are inserted. They are related to the orientations that are necessary for the Nursing team, the patient and the caregiver, and are defined after the identification of risk by: medical record; orientation of the caregiver; orientation of the Nursing team; orientation of the patient, and recommendation of a full-time caregiver. These functions are represented in figure 3, in green.

From the orientation given to the Nursing team (<orientate the nursing team>) and the identification of risk (<identify risk>), seven other functions, represented in purple, are added. These functions deal with actions to be implemented in the work process: <keep the bed wheels locked>; <keep the environment illuminated>; <keep the bed rails elevated>; <keep personal objects close by>; <keep the bed lowered>; <walking with companion> and < guarantee walking with companion >.

The functions medical record (<medical record>) and implementation of care (seven purple colored functions in figure 3) occur simultaneously. The boundary function of this modeling is <adhere to protocol>. The output variability of all functions upstream of this one reflects in not fully adhering to the protocol, potentially triggering a crash event.

The representation of the functions by colors elucidates the different moments in which the SOP is implemented by grouping actions: i) yellow: conditions for the application of the fall risk scale; ii) green: orientations and registers; iii) blue: visual signaling of patients who have risk of falling to professionals; iv) purple: prescribed care to prevent falling; v) red: modeling limit.

Critical functions are those related to the orientation of patients, companions, and the Nursing team. This identification can be evidenced by the number of couplings perceived downstream of the functions. Functions with more upstream couplings have a greater chance of receiving variability, such as the function <identify risk>, with eight upstream couplings, and the function <adhere to protocol>, also with eight upstream couplings, while functions with a greater number of downstream couplings may increase the variability repercussions of their output.

Regarding to the design of the final process, it is, in its entirety, human-dependent and its functions are characterized in the FRAM Model Visualizer software as human. The beginning of the process is performed by the nursing professional and the evaluation of the risk score and the orientation of the Nursing team, and all other functions are of the Nursing team.

4.2 Step 2 - Identification of falls with moderate to severe injury

As identified in the institutional notifications, a total of 447 falls were notified from July 1^st, 2018, to July 31^st, 2019. Among those falls, 242 (54.1%) were related to the clinical and surgical inpatient units and, among them, 12 (2.7 %) represent the falls with moderate to severe injury.

There were no deaths resulting from falls in the analyzed period.

4.3 Step 3 – Modeling the work-as-done

The 12 falls were analyzed from the prescribed work modeling (Figure 3), being identified which functions presented variability. After this analysis, the falls were grouped into four instantiations (F.

The falls grouped in each instantiation presented variability in the same functions. Thus, in instantiation A, falls 1 and 11 presented real variability in the functions: <be aware of the use of sensory and muscle strength altering drugs >; <perceive change in the patient's general state>; <orientate companion>; <recommend companion>; <guarantee walking with companion>. Instantiation B, in turn, represents the falls 2, 3, and 12 in which there was variability in the functions: <perceive change in the patient's general state>; < guarantee walking with companion>; <identify risk>.

The highest number of falls is found in instantiation C, contemplating falls 4, 5, 6, 7, 8, and 9. Only two functions presented variability in instantiation C: <orientate companion> and <guarantee walking with companion>. Finally, instantiation D, from fall 10, presented the greatest number of functions with real variability. In this instantiation, seven functions presented variability: <identify risk>; <identify bleeding risk>; <put on bracelet>; <be aware of the use of sensory and muscle strength altering drugs>; <orientate companion>; <orientate patient>; <orientate the Nursing team>.

It is worth mentioning that some functions presented variability in more than one instance: (i) <guarantee walking with companion> presented variability in instantiations A, B and C (falls 1, 2, 3, 4, 5, 6, 7, 8, 9, 11 and 12) and only fall 10 did not present real variability in this function; (ii) the function <orientate companion> presented variability in instantiations A, C and D (falls 1, 4, 5, 6, 7, 8, 9, 10 and 11); (iii) <perceive change in the patient's general state> showed variability in the instantiations (falls 1, 2, 3, 11, and 12); (iv) <identify risk> showed variability in the instantiations B and D (falls 2, 3, 10, and 12) and the function <attend to the use of drugs that alter sensory and muscle strength> showed variability in the instantiations A and C (falls 1, 10, and 11).

Figure 4 shows the modeling of one of the presented instantiations: the instantiation C.

All instantiations were modeled, however, we chose to present C since: (i) the functions with variability in this instantiation (<orientate companion> and <guarantee walking with companion>) also presented real variability in other two instantiations; (ii) it presents the highest number of related falls (falls 4, 5, 6, 7, 8 and 9).

In addition to the 22 functions identified earlier, when the event occurs, other functions emerge. Thus, instantiation C presents 31 functions. The nine functions that emerged during or after the fall event are: <perceive fall>; <assess nurse>; <assess physician>; <administer post-fall care/prescription>; <solicit specialist>; <assess exams>; <define severity and conduct>; <prescribe conduct>; <notify event>. The new functions represented are: i) black color: the falls verified, corresponding to instantiation C; ii) gray color: the evaluations of the nurse, physician and specialist; iii) light blue color: the new care needed to treat the fall; iv) orange color: the diagnostic exams and the indication of treatment, as well as the feasibility of necessary conducts depending on individual factors of each patient; v) pink color: the need to notify the adverse event.

In addition to the functions that were incorporated and now constitute work-as-done, preexisting functions, such as <medical record> and <guidance to companion>, received other couplings. In the function of register in medical record, upstream, there was an increase from three to eight couplings, and in the accompanying person orientation, the variation was downstream with the incorporation of one more coupling.

4.4 Step 4 - Reflections on the gap between work-as imagined and work-as-done

The reflections on the gap between WAI and WAD occurred during the fourth stage of the study in interviews with professionals. Thus, from the modeled falls, a fall was presented to the study participants to understand the difficulties identified for the effectiveness of the institutional protocol.

“(...)I lower the bed, explain why, reinforce the issue of having to have the bars up, which is something that patients have a lot of resistance, they don't like to have the bars up, even with the risk of falling, because I believe they feel trapped, with their freedom limited. I also put myself in their place (...) sometimes, we end up making the bars more flexible, which favors a fall.” (NURS 2, emphasis added)

“(...)she was wearing a bracelet, but she asked for the grid to be lowered, but the patient can't ask, she was an elderly woman (...), she wanted to be mobile.” (NURS 4, emphasis added)

Professionals' strategies used to account for variability related to patients' attitudes (orientate companion>, <recommend companion>, <guarantee walking with companion>).

“the bells have a bad wire, (...) a short wire, so we tie a compress to make it longer for the patient.” (NURS 5, emphasis added)

“(...)by the protocol, most of the care that we prescribe or that is in the protocol, we perform, but the end result is not always as expected, (…) sometimes we prescribe to request the presence of a family member, but the family member, does not come or comes, but does not pay attention and sleeps (...), but I think that, no matter how much we prescribe, there is this distance between the real and the prescribed (...) it is absurd, but we count on the neighbor's companion to provide support.” (NURS 6, emphasis added)

“(...)if there is no companion, what is the need for restraint, if you check with the medical team if there is a need for restraint. If you try to enter the room more, visit the patient more, also try to review if you can have a companion if the patient is alone.” (NT13, emphasis added)

“(...)or they orient the patients that they can walk pushing the IV drip stand and then it weighs, turns and the patient falls, sometimes there are two or three pumps in the stand, they also have to be educated for this.” (NT 12, emphasis added)

Sometimes the daily doer needs to find individual strategies to ensure patient safety, which sometimes ends up being incorporated by other colleagues.

“I try to do what I call a crib protector, which is to take the two transfers of the patient and put one on each side of the bed, which makes falling more difficult, besides containing (...), most of them are already adhering to my idea because the beds are comfortable, but they are inappropriate (...) in winter, they stay uncovered a lot (...) I make a hut for them and I try to go to the room more often (...).” (NT1, emphasis added)

“(...)leave only his chair and don't leave another chair on the way back, take care of the slippers because, sometimes, when he gets up, he puts his feet together and ends up falling down.” (NT14, emphasis added)

Thus, the Nursing team becomes vigilant to the vulnerabilities of hospitalization. In this vigilance, nurses and nursing technicians need to share, with the multi-professional team, the responsibilities regarding the risk of falling, as shown in the following excerpt.

“(...)the physical therapists (...) take the patients to walk in the corridor and don't orient them that they can't walk alone (...). The doctors, when they go to check on the patients, lower the bars and don't lift them, they go to do some procedure and also leave the beds high. Collection personnel... I think it is something kind of general (...).” (NT12, emphasis added)

The professionals identify that the SOP implementation does not guarantee the elimination of falls and they use their experiences and expertise to glimpse other latent situations that can contribute to the occurrence of falls, once the protocol cannot cover all the possible situations that can result in the variability represented by falls.

“(...)I will take off the socks and put a sheet on the floor because, with the sock, he will slide with this wool sock (...) we are protecting the patient.” (NT4, emphasis added)

In addition, the professionals report the importance of shared work through a cohesive team, with previously built bonds, in favor of a common goal.

“(...)when there is a fixed person in the team, who is here every day, (...) the same person, we start to talk as a team and this flows very well. So, now, for example, when we are rotating more, when we don't have a fixed person, these problems increase.” (NTF7, emphasis added)

Still, the professionals interviewed brought suggestions to reinforce the patient's understanding about the risk of falling, revealing the need for greater awareness.

“(...)also, besides a little film, a little folder, because, if he doesn't understand, look there, (...), but it's a little thing that some scenes, if he sees that film or reads that there, something, he will record (...) explaining which are the risks of falling and such, what he should do to avoid (...).” (NT6, emphasis added)

Suggestions for improvement are also made regarding the environment, which has implication on the variabilities related to the Nursing team's competencies (<perceive change in patient's general condition>, <guarantee walking with companion>, <identify risk>).

“Safety bars on the shower stalls and something on the door (...) should have some locks.” (NT7, emphasis added)

“Low-light, light-on-the-way type, as soon as they are activated by movement.” (NURS6, emphasis added)

(...)the patients bring a lot of things, (...) like the TV, it gets in the way, wires on the floor, fan, it gets in the way a lot, (...) three extension cords in the room, it also causes them to fall.” (NT8, emphasis added)

The identification of opportunities for improvement in the environment shows the professional's commitment to qualify the assistance and bring the prescribed work closer to the real work.

During the studied period, 447 falls occurred. Although the 12 falls with moderate to severe injury may seem unrepresentative (2.7%), its analysis allows extrapolation of the result to the other falls in the institution with less severity of injury. This statement is based on the principle of equivalence (Hollnagel, 2018), which states that situations with positive or negative outcomes arise from the same processes. The reflection and the opportunities for improvement identified in the process will also reflect in the reduction of events with less severe outcomes, besides increasing the quality of care of events with positive outcomes.

Reflecting on the variability of the functions identified in the event of a fall, it can be seen that the function <guarantee walking with companion>, for example, presented variability in 11 of the 12 falls analyzed. Aligned with the principle of equivalence, it is understood that the variability of this function and of the other functions with variability can also be present in situations in which the fall does not occur, but could occur.

Fall risk assessment makes it possible to proactively identify patients who are likely to fall. However, when the patient has prescribed care (falls 1, 4, 6, 9,11) and to these risks are not foreseen stepped care, a careful look is not made to this process and all patients with risk, whether low, medium or high, are cared for in the same way (Kafantogia et al., 2017).

Falls occur due to an accumulation of risk factors, thus the importance of acting on known risk factors so that patients can benefit from prevention (Kenny et al., 2017), offering the caregiver the opportunity to determine the type of care the patient should receive (Kafantogia et al., 2017), so that the care prescribed can make sense to the caregiver, avoiding the trivialization of visual identification represented by the use of a fall bracelet.

It should also be noted that there are falls that can be anticipated, falls that cannot be anticipated, and accidental falls (Australian Commission on Safety and Quality in Health Care, 2009). Thus, there are falls in which the assessment tool can be predictive (falls 1,4,6,9 and 11), those in which the tool does not identify the risk (falls 2 and 3) and the others in which the patient was not identified with the risk of falling (falls 7 and 10), but, due to problems related to the work process or the environment, they end up occurring (Tinetti & Kumar, 2010).

Falls related to the work process and the environment are the second most common group of falls after that of anticipatory falls (Neily et al., 2005). These falls, although categorized differently, occur in the same way, and it is to these that the focus of prevention should be directed. However, there are falls 5, 8, and 12 in which, even if the risk was identified, care was not implemented to prevent it.

Facing a number of falls that are not sensitive to the prediction instruments, the professionals' expertise is of great value in reducing them in order to make them avoidable. It is under this perspective the need to develop risk perception. Situations not foreseen in the protocol are supported by the tacit knowledge of the professionals and provide the reduction of the gap between the WAI and WAD (Vechter & Drach-Zahavy, 2021). Besides expertise, individual strategies, the sharing of ideas and the construction of common goals, with a cohesive work team and bond between members, make it possible to reduce the variability that affects the gap between WAI and WAD.

In relation to the analysis of instantiation C (falls 4, 5, 6, 7, 8 and 9), variability can be seen in the function <orientate companion>, with nine functions implicated in the WAI and ten in the WAD. Throughout the patient's hospitalization, a large number of orientations are necessary, and these are performed by different professionals (nurses and Nursing technicians), in different shifts. In addition, the orientation is directed to a multiplicity of patients and family members/caregivers with different levels of understanding. This example illustrates the complexity inherent in hospitals, admittedly SSC, which have a large number of elements (human and equipment) that interact with each other dynamically, which may result in a greater unexpected variability (Saurin & Gonzales, 2013).

This variability sometimes impacts the fall as the final outcome, closely related to quality of care and patient safety (Kafantogia et al., 2017). In addition to identifying that a large number of professionals perform orientation, once again reinforces the characteristics of CSS, i) large number of elements that interact dynamically and ii) diversity of elements (Saurin & Gonzales, 2013), and additionally to this, the companion, further increasing the variability in this process, which is maintained by the uniqueness of patients and their companions (Braithwaite et al., 2018), contributing to variability in the final outcome.

Another variability that permeates instantiation C concerns the function <guarantee walking with companion>, with five couplings in the prescribed work and six in the actual work. The variability represented by this function brings an additional challenge to professionals who need to guarantee this accompaniment in the patients' displacements, but in practice, due to the volume of work, it is not possible.

In addition, this item of the prescription goes against the care of the patient, who needs to mobilize himself, in an increasingly earlier way, counting on the companion to help him, but is stimulated to become independent as a way to actively participate in his care. On the other hand, increasingly complex work processes, demanding attention and, consequently, a greater workload, mean that this wandering of patients is sometimes not accompanied by the professionals.

The effort of the professionals to contemplate the patients' needs, when they do not raise the bars, by request of the patients, or even when they tie a compress to make the bell wire longer and reduce the effort of the patients, in a certain way, has repercussions in the patient's safety when these flexibilities have a fall as an outcome. The empathy of professionals who are sensitized by noticing the absence of a companion, because they understand that there is no other way to occupy the patients' time and mind, sometimes provides the distance between the real work and the prescribed work. Thus, investment in the education of patients and companions is fundamental to ensure the safety and qualification of the assistance provided (Barbosa et al., 2019; Falcão et al., 2019), in addition to bringing them closer to the prescribed care.

To make patients partners in their care, it is important to involve them in the care plan, in the orientation of the risks involved and in the prevention of falls (Gu et al., 2016). A suggestion for improvement, presented by the study participants and aligned with these statements, is the presentation of educational videos and folders. Other equally important alternatives relate to the environment, revealing the need to strengthen safety barriers in the context of hospitalization.

By looking at the expertise of the professionals, suggestions for improvement in the work environment should be valued. The suggestions presented do not eliminate the risk of patients falling, but constitute multimodal strategies of approach to the issue of falls, which value and involve the actors of care. Another way of valuing is the sharing of experiences and the dissemination of practices such as the use of "transfers" with the purpose of being a bed protector and preventing the patient from falling through the bars. Actions such as this one demonstrate the concern to ensure adherence to the fall protocol, but more than fulfilling tasks, participation in the work process and actions for patient safety are important (Gu et al., 2016). One has to consider how much the valorization by the leadership stimulates the protagonism of the professionals and reduces the trivialization of all the quantitative falls that occur.

The complexity of the hospital environment provides that, to meet a range of specificities of the patients, it is proposed the incrementation of protocols, routines and SOPs. In a certain way, this is the formal guarantee that the professionals seek to base their actions on, however, the sum of multiple individual protocols does not have real value when the same patient has multiple risks, that is, the sum of the parts does not translate the whole.

An elderly patient, with delirium, without prescribed fall prevention care, without a bracelet (fall 8), in which the fall leads to injury of the occipital region, or even a young adult patient, who does not score in the fall risk assessment tool, using anticoagulant, which, by itself, provided a fall of great repercussion (orbit fracture, skull trauma, new surgery), reflects in the increase of hospitalization time (Severo et al., 2014), in hospital costs (Gu et al., 2016;), on the image of the institution (Falcão et al., 2019 e Barbosa et al., 2019)and the repercussions for caregivers. These falls have the potential to be catastrophic and mitigating this injury is a big challenge, but it's by looking at situations like this that you have to think about safer systems that can help caregivers.

Regarding the prescription and the fulfillment of the ideally planned work, the appeal to the nursing professionals is noticeable. There are specific items of orientation to the Nursing team who also implement them, but the patient is seen by a multi-professional team. Faced with a process as complex as falls, the involvement of communication between the different actors of care becomes fundamental (Kafantogia et al., 2017), because successful fall management involves communication, SOPs, protocols, and teamwork (Kenny et al., 2017).

The management of a multi-professional commission, such as the falls commission, is an important step to rethink work processes. This is a strategy that seeks to meet a challenge in the global scenario of patient safety represented by falls, but it is necessary to guarantee multi-professional care practices. The literature reports that doctors don't know how to identify where the fall scores are in the patient's records (Damoiseaux-Volman et al., 2021) or that the fall risk scale is not routinely discussed in all meetings of the different care teams involved in the care. These structural differences have repercussions in the differences of approach of the institution (Häggqvist et al., 2012) and end up shaping behavior.

The investment in collaborative practices presupposes the sharing of work processes, not only the doing, but also the planning, improving the continuity of care and patient safety (McHugh et al., 2020). To this end, organizations should invest in shared strategies as a way to improve work teams and patient benefits (Schmutz et al., 2019). Involving the actors of care, understanding the difficulties, and testing suggestions provides a better involvement, promotes healthy relationships, and allows the horizontal construction of the work. This discussion, when it occurs, provides a greater sense of belonging to the teams.

The speeches of the professionals can have recall implications and the cross-sectional design can also be considered a limitation of the study, as well as the impossibility of generalization, considering the local context of the study. It is also necessary to ponder that the research developed addressed the vision of Nursing about falls and, considering the multiprofessional dimension that this modality of risk requires, this is considered a limitation of the study. A complementary approach on the fall of adult hospitalized patients is presented by Quadros et al. (2022) which analyzed the same events considering the nursing worker as a second victim perspective.

5.1 Limitation

Regarding the limitation of the study, it is sensitive to the context used, because the modeling of the work process was performed from records of a specific context, but does not invalidate the modeling in other environments, given the peculiarities of the scenario used.

5.2 Application to practice

The understanding of the variability in the occurrence of falls has an impact on the prevention and reduction of injuries to hospitalized patients, affecting the safety and quality. Besides, professionals can identify the difficulties for patients to adhere to the protocol and the possibilities of mitigating the occurrence of falls.

The use of WAI and WAD modeling allowed the identification of critical factors in the care process that contribute to the occurrence of falls.

The findings of the study indicate that the variability inherent to the daily work in fall prevention are related to the assurance of accompanied walking, orientation of the companion, verification of the change in the patient's general state, identification of risks and the use of drugs that alter the sensory or muscle strength. To deal with the variability, the nursing professionals identified opportunities for improvement on the aspects related to the understanding of the patient's risk, which requires insistence on the maintenance of the bed rails, resources for comfort and barriers to the unnecessary exit of the bed.

As for the variability related to the competencies of the Nursing team, the professionals interviewed listed the necessary improvements in the environment and structure. A greater perception of risk of falls can contribute to reduce the distance between WAI and WAD.

This study is innovative in the triangulation of the theme of falls, in the use of process modeling and in the scenario of the work prescribed and performed. In addition, it identifies the importance of the multiprofessional work and allows the verification of strategies used in the care practice to contemplate the final objective of mitigating the repercussions of falls, even when the care protocol cannot predict all the situations that put the patient at risk of falling.

CCS Complex Sociotechnical Systems

CONEP National Research Ethics Council (CONEP)

COREQ Consolidated Criteria for Reporting Qualitative Research

FRAM Functional Resonance Analysis Method

NT Nursing Technician

NURS Nurse

RE Resilience Engineering

REC Research Ethics Committee

SOP Standard Operational Procedure

WAD wor as done

WAI Work as imagined

Ethics approval and consent to participate

This study was written based on the Helsinki ethical principles for medical researches and approved by the Ethics Committee of Hospital de Clínicas de Porto Alegre of Federal University of Rio Grande do Sul, under Opinion nº 2.554.758

Consent for publication: Not applicable

Availability of data and materials

The datasets generated and/or analysed during the current study are not publicly available due to they belong to a corresponding author’s master degree thesis. They will be available after july 2023 or under reasonable request to the corresponding author.

Competing interests

The authors declare that they have no competing interests

Funding: Not applicable

Authors' contributions

QUADROS DV; WACHS P; MAGALHÃES AMM; DAL PAI D: Conceptualization

QUADROS DV; WACHS P; MAGALHÃES AMM; DAL PAI D: Methodology QUADROS DV; WACHS P; MAGALHÃES AMM; DAL PAI D: Supervision QUADROS DV; WACHS P; MAGALHÃES AMM; SEVERO IM; TAVARES

JP; DAL PAI D: Writing-Reviewing and Editing,

QUADROS DV; WACHS P; MAGALHÃES AMM; SEVERO IM; TAVARES

JP; DAL PAI D : Visualization

QUADROS DV; WACHS P; MAGALHÃES AMM; DAL PAI D: Investigation QUADROS DV; MAGALHÃES AMM: Data Curation

MAGALHÃES AMM: Project Administration

All authors read and approved the final manuscript

Acknowledgements: Not applicable

Daily work variability in falls prevention of hospitalized patients: Nursing team’s perception

List of all authors

*Deise Vacario de QUADROS ^1,2

Priscila WACHS ³

Ana Maria Müller de MAGALHÃES²

Isis Marques SEVERO¹

Juliana Petri TAVARES ^1,2

Daiane DAL PAI ^1,2

Affiliations

¹Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil

²Federal University of Rio Grande do Sul, Brazil

³Pontifical Catholic University of Rio Grande do Sul, Brazil

*Corresponding author

[email protected]

Ashour, A., Ashcroft, D. M., & Phipps, D. L. (2021). Mind the gap: examining work-as-imagined and work-as-done when dispensing medication in the community pharmacy setting. Applied Ergonomics, 93, 103372. https://doi.org/10.1016/j.apergo.2021.103372
Australian Commission on Safety and Quality in Health Care. (2009). Preventing falls and harm from falls in older people: best practice guidelines for Australian residential aged care facilities. https://www.safetyandquality.gov.au/sites/default/files/migrated/30458-Guidelines-RACF.pdf
Barbosa, A. S., Chaves, E. H. B., Ribeiro, R. G., Quadros, D. V., Suzuki, L. M., & Magalhães, A. M. M. (2019). Characterization of the adult patients’ falling incidents in a university hospital. Revista Gaúcha de Enfermagem, 40(esp), e20180303. https://doi.org/10.1590/1983-1447.2019.20180303
Bardin, L. (2011). Análise de conteúdo. Edições70.
Braithwaite, J., Churruca, K., Long, J. C., Ellis, L. A., & Herkes, J. (2018). When complexity science meets implementation science: a theoretical and empirical analysis of systems change. BMC medicine, 16(1), 63. https://doi.org/10.1186/s12916-018-1057-z
Carlesi, K. C., Padilha, K. G., Toffoletto, M. C., Henriquez-Roldán, C., & Juan, M. A. C. (2017). Patient safety incidents and nursing workload. Revista Latino-Americana de Enfermagem, 25, e2841. https://doi.org/10.1590/1518-8345.1280.2841
Clay-Williams, R., Hounsgaard, J. & Hollnagel, E. (2015). Where the rubber meets the road: using FRAM to align work-as-imagined with work-as-done when implementing clinical guidelines. Implementation Sci, 10(125). https://doi.org/10.1186/s13012-015-0317-y
Damoiseaux-Volman, B. A., Medlock, S., van der Eijk, M. D., Romijn, J. A., Abu-Hanna, A., & van der Velde, N. (2021). Falls and delirium in older inpatients: work-as-imagined, work-as-done and preferences for clinical decision support systems. Safety Science, 142, 105355. https://doi.org/10.1016/j.ssci.2021.105355
Falcão, R. M. M., Costa, K. N. F. M., Fernandes, M. G. M., Pontes, M. L. F., Vasconcelos, J. M. B., & Oliveira, J. S. (2019). Risk of falls in hospitalized elderly people. Revista Gaúcha de Enfermagem, 40(spe), e20180266. https://doi.org/10.1590/1983-1447.2019.20180266
Gu, Y. Y., Balcaen, K., Ni, Y., Ampe, J., & Goffin, J. (2016). Review on prevention of falls in hospital settings. Chinese Nursing Research, 3(1), 7-10. https://doi.org/10.1016/j.cnre.2015.11.002
Häggqvist, B., Stenvall, M., Fjellman-Wiklund, A., Westerberg, K., & Lundin-Olsson, L. (2012). “The balancing act” – licensed practical nurse experiences of falls and fall prevention: a qualitative study. BMC Geriatrics, 12, 62. https://doi.org/10.1186/1471-2318-12-62
Heng, H., Jazayeri, D., Shaw, L., Kiegaldie, D., Hill, A. M., & Morris, M. E. (2020). Hospital falls prevention with patient education: a scoping review. BMC Geriatrics, 20(1), 140. https://doi.org/10.1186/s12877-020-01515-w
Hollnagel, E., Woods, D., & Leveson, N. (2006). Resilience Engineering: concepts and precepts. Ashgate.
HOLLNAGEL, E. (2011). Prologue: the scope of Resilience Engineering. In Resilience Engineering in Practice: a guidebook (pp. XXIX-XXXIX). Ministry of Social Affairs and Health and European Observatory on Health Systems and Policies. Ashgate.
Hollnagel E. (2018). FRAM – The Functional Resonance Analysis Method – a brief guide on how to use the FRAM. https://functionalresonance.com/onewebmedia/Manual%20ds%201.docx.pdf
Institute of Medicine (US) Committee on Quality of Health Care in America, Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (Eds.). (2000). To Err is Human: Building a Safer Health System. National Academies Press (US). https://pubmed.ncbi.nlm.nih.gov/25077248/
Joint Commission International. (2021). Joint Commission International Accreditation Standards for Hospitals (7th ed.). Joint Commission International. https://www.jointcommissioninternational.org/-/media/jci/jci-documents/accreditation/hospital-and-amc/jci-errata-standards-only_7th-ed-hospital.pdf
Kafantogia, K., Katsafourou, P., Tassiou, A., & Vassou, N. (2017). Falls among hospitalized patients. Journal of Frailty, Sarcopenia & Falls, 2(3), 53-57. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7161932/pdf/JFSF-2-053.pdf
Kenny, R. A., Romero-Ortuno, R., & Kumar, P. (2017). Falls in older adults. Medicine, 45(1), 28-33. https://doi.org/10.1016/j.mpmed.2016.10.007
Lipsitz, L. A. (2012). Understanding health care as a complex system: the foundation for unintended consequences. JAMA, 308(3), 243-244. https://dx.doi.org/10.1001%2Fjama.2012.7551
McHugh, S. K., Lawton, R., O’Hara, J. K., & Sheard, L. (2020). Does team reflexivity impact teamwork and communication in interprofessional hospital-based healthcare teams? A systematic review and narrative synthesis. BMJ Quality & Safety, 29(8), 672-683. https://doi.org/10.1136/bmjqs-2019-009921
Minayo, M. C. S., & Guerriero, I. C. Z. (2014). Reflexity as the ethos of qualitative research. Ciência e Saúde Coletiva, 19(4), 1103-1112. https://doi.org/10.1590/1413-81232014194.18912013
Neily, J., Howard, K., Quigley, P., & Mills, P. D. (2005). One-year follow-up after a collaborative breakthrough series on reducing falls and fall-related injuries. Joint Commission journal on quality and patient safety, 31(5), 275–285. https://doi.org/10.1016/s1553-7250(05)31035-x
Peter, E. (2015). The ethics in qualitative health research: special considerations. Ciência & Saúde Coletiva, 20(9), 2625-2630. https://doi.org/10.1590/1413-81232015209.06762015
Quadros, D.V., Magalhães, A.M.M., Wachs, P., Severo, I.M., Tavares, J.P., & Dal Pai, D. (2022). Modeling of adult patient falls and the repercussions to Nursing as a second victim. Rev. Latino-Americana de Enfermagem, 30, e3618. https://doi.org/10.1590/1518-8345.5830.3618
Righi, A. W., & Saurin, T. A. (2015). Complex socio-technical systems: Characterization and management guidelines. Applied ergonomics, 50, 19–30. https://doi.org/10.1016/j.apergo.2015.02.003
Rosso, C. B., & Saurin, T. A. (2018). The joint use of resilience engineering and lean production for work system design: A study in healthcare. Applied ergonomics, 71, 45–56. https://doi.org/10.1016/j.apergo.2018.04.004
Saurin, T. A., & Gonzalez, S. S. (2013). Assessing the compatibility of the management of standardized procedures with the complexity of a sociotechnical system: case study of a control room in an oil refinery. Applied ergonomics, 44(5), 811–823. https://doi.org/10.1016/j.apergo.2013.02.003
Schmutz, J. B., Meier, L. L., & Manser, T. (2019). How effective is teamwork really? The relationship between teamwork and performance in healthcare teams: a systematic review and meta-analysis. BMJ Open, 9(9), e028280. https://doi.org/10.1136/bmjopen-2018-028280
Severo, I. M., Kuchenbecker, R. S., Vieira, D. F. V. B., Lucena, A. F., & Almeida, M. A. (2018). Risk factors for fall occurrence in hospitalized adult patients: a case-control study. Revista Latino-Americana de Enfermagem, 26, e3016. https://doi.org/10.1590/1518-8345.2460.3016
Severo, I. M., Almeida, M. A., Kuchenbecker, R., Vieira, D. F. V. B., Weschenfelder, M. E., Pinto, L. R. C., Klein, C., Siqueira, A. P. O., & Panato, B. P. (2014). Risk factors for falls in hospitalized adult patients: an integrative review. Revista da Escola de Enfermagem da USP, 48(3), 537-531. https://doi.org/10.1590/S0080-623420140000300021
Severo, I. M., Kuchenbecker, R., Vieira, D. F. V. B., Pinto, L. R. C., Hervé, M. E. W., Lucena, A. F., & Almeida, M. A. (2019). A predictive model for fall risk in hospitalized adults: a case-control study. Journal of Advanced Nursing, 75(3), 563-572. https://doi.org/10.1111/jan.13882
Souza, V. R. S., Marziale, M. H. P., Silva, G. T. R., & Nascimento, P. L. (2021). Translation and validation into Brazilian Portuguese and assessment of the COREQ checklist. Acta Paulista de Enfermagem, 34, eAPE02631. https://doi.org/10.37689/actaape/2021AO02631
Stephenson, M., Mcarthur, A., Giles, K., Lockwood, C., Aromataris, E., & Pearson, A. (2016). Prevention of falls in acute hospital settings: a multi-site audit and best practice implementation project. International Journal for Quality in Health Care, 28(1), 92-98. https://doi.org/10.1093/intqhc/mzv113
Tinetti, M. E., & Kumar, C. (2010). The patient who falls: “it’s always a trade-off”. JAMA, 303(3), 258-266. https://doi.org/10.1001/jama.2009.2024
Vechter, T., & Drach-Zahavy, A. (2021). Effect of nurses' resilience on fall prevention in acute-care hospital: a mixed-methods qualitative study. Journal of Nursing Management, 29(7), 2199-2207. https://doi.org/10.1111/jonm.13373
Wachs, P., Saurin, T. A., Righi, A. W., & Wears, R. L. (2016). Resilience skills as emergent phenomena: A study of emergency departments in Brazil and the United States. Applied ergonomics, 56, 227–237. https://doi.org/10.1016/j.apergo.2016.02.012
Wachs, P., & Saurin, T. A. (2018). Modelling interactions between procedures and resilience skills. Applied ergonomics, 68, 328–337. https://doi.org/10.1016/j.apergo.2017.12.013
World Health Organization. (2008). World Alliance for Patient Safety. Summary of the evidence on patient safety: implications for research. https://apps.who.int/iris/bitstream/handle/10665/43874/9789241596541_eng.pdf?sequence=1&isAllowed=y
World Health Organization. (2009). Conceptual framework for the International Classification for Patient Safety: final technical report. https://apps.who.int/iris/bitstream/handle/10665/70882/WHO_IER_PSP_2010.2_eng.pdf?sequence=1&isAllowed=y
World Health Organization. (2020). Charter health worker safety: a priority for patient safety. https://www.who.int/docs/default-source/world-patient-safety-day/health-worker-safety-charter-wpsd-17-september-2020-3-1.pdf?sfvrsn=2cb6752d_2

No competing interests reported.

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Daily work variability in falls prevention of hospitalized patients: Nursing team’s perception

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