Knowledge, Attitudes on Fall and Awareness of Hospitalized Patient’s Fall Risk Factors Among the Nurses Working in Tertiary Care Hospitals.

Back ground: Fall is the most common patient safety incident in health care organization. This study was initiated to obtain information regarding knowledge & attitude on fall and awareness of fall risk factors among nurses to device evidence based and multidisciplinary educational and training programme to improve patient safety and thereby reducing morbidity and mortality associated with fall. Methods: A descriptive cross sectional survey study was conducted among 339 registered nurses working in Tertiary care hospitals across Chennai, Tamil Nadu, India. Modied version of previously validated standard questionnaire was administered by the investigators through online survey method to explore the level of knowledge &attitude on fall and awareness of inpatient fall risk factors among Nurses. Results: In this study, 15.6% of participants had adequate knowledge on fall, 57.2% had favorable attitude towards fall and 38.3% adequate awareness on fall risk factors. Years of experience in nursing has statistical signicant association with level of knowledge on fall. The participant’s attitude towards fall had statistical signicant relationship with age, education, experience in nursing and previous patient fall experience. The correlation between fall knowledge, attitude of fall and awareness of fall risk factors were highly signicant. Majority of the participants expressed their favorable attitude towards need for fall preventive education. Conclusion: In our study, it is evident that there is a void which has to be lled to improve the knowledge, attitude and awareness on fall and its risk factors .There is a need for extensive education and holistic, multifactorial and interdisciplinary training program to be undertaken through various health care organizations.


Introduction
A fall is de ned as an event which results in a person coming to rest inadvertently on the ground or oor or other lower level (1). Falls and its consequences are major public health problem, making it the second leading cause of accidental deaths worldwide (2). Fall is reported as the most frequent patient safety event occurring in hospitals3. Fall occur at a rate of 3-5 per 1,000 occupied bed-days, and the Agency for Healthcare Research and Quality estimates that each year 700,000 to 1 million hospitalized patients fall (4). Nearly one in every three inpatients aged 65 years and older sustains fall. The traumatic complications of fall includes physical injury, functional impairment, increased rate of hospitalization and delayed recovery as a result people suffer a lot with a huge burden to the family, health sector, and economy of the country (5,6,7). A signi cant proportion of non-traumatic falls, often instill fear of fall-a post fall syndrome which includes dependency, loss of autonomy, confusion, immobilization, and depression, which will lead to a further restriction in daily activities and thus affects Quality of life (8,9).
Despite the continued efforts to decrease falls in the hospital settings, there continues to be an increased incidence of inpatient falls. Nurses are the true backbone for any health facility. They provide constant care to patients and it is important that they are properly trained to identify risk factors and employ strategies to prevent them. Due to demanding working schedule, lack of awareness, complex patient pro les, there are high chances that preventable aspect of these "geriatric giants" are not well addressed and often overlooked. Knowledge and attitude of nurses attribute to disseminate and establish a foundation for fall preventive activities in Tertiary care hospitals. Even though falls among hospitalized patient is a well-recognized topic in both nursing and medical literature, in many developing countries it has not been prioritized for research. Hence, the current study had been devised to nd out these lacunae and establish the best care for the patients.

Measures
Modi ed version of previously validated standard questionnaire was administered by the investigators comprised on 52 questions/ statements on demographic characteristics and information pertaining to the fall and its risk factors. The demographics were followed by 3 sections with set of questions/statements. The Section-1 incorporated 16 simple questions, to assess the knowledge on fall

Statistical analysis
Each statement/ question was numerically coded to obtain score for knowledge and attitude of fall and awareness of fall risk factors. All the categorical variables are presented as numbers and percentages.
Descriptive analysis was performed using univariate statistics to report the Mean and Standard Deviation (SD) for the continuous variable and frequency distributions for the categorical variables. Correlation, non-parametric tests of Kruskal-Wallis and Mann-Whitney Test were performed to compare differences in the variables. All reported statistically signi cant differences were calculated at the 95% con dence level.
Spearman's rho test measured the strength and direction of the relationship between two variables. Chisquare test was used to assess the association between categorical variables. Statistical signi cance was set at < 0.05. All statistical analyses were performed using Statistical Package for Social Science (SPSS, version 17) for Microsoft windows, SPSS Inc. USA.

Results
Of the 439 participants who were intended to receive survey questionnaires, 339 participants submitted completed questionnaires: a response rate of 75% leaving 339 valid for analysis.

Knowledge on fall
Considering overall level of knowledge of the 339 participants, 26.8% (n = 91) of individuals had inadequate knowledge, 57.5% (n = 193) had moderately adequate knowledge, and 15.6% (n = 53) had adequate knowledge on fall. (Fig. 1) .The average mean knowledge of the study participants was10.05 ± 2.219 (Table 5). Correlation between level of knowledge and participants' years of experience in nursing alone showed statistically signi cant relationship at p0.01 among all the selected demographic variable. (Table 6) Similarly only years of experience in nursing has statistical signi cant association (p0.01) with level of knowledge on fall. (Table 7) The statements concerned with diseases condition and medications related to fall as expressed by the participants represented lowest of all knowledge scores were: 42% for "Taking medicine for diabetics is not related to fall" and "Intravenous therapy or intravenous access has a risk for fall,".46% for "Depression is not related to fall and 47.2% for Taking medicines for blood pressure is not related to fall" ( Table 2) Attitude towards fall In this present study, 2% (n = 6) had unfavorable attitude, 42.2% (n = 143) had moderately favorable attitude and 57.2% had favorable attitude towards fall. (Fig. 1) 49.69 ± 5.746 was the average mean attitude of the study participants. (Table 5) The participants' attitude towards fall had statistical signi cant relationship at p0.001 with age, education, experience in nursing and previous fall experience at p0.05. (Table 6)There were statistical signi cant associations between attitude of fall with age (0.05), gender (p0.001), educational quali cation (p < 0.001) and experience in nursing (p 0.001). (Table 7) The lowest mean score for the statements on attitude of fall were: 2.58 ± 1.24 for the statement" hospital environment is safe for fall". 2.66 ± 1.26 for "fall is unavoidable" Majority of the participants expressed their favorable attitude towards need for fall preventive education. 4.56 ± 0.74 (Table.3)

Awareness of fall risk factors
The participants level of awareness on fall risk factors were 38.3% (n = 130) adequate, 52.2% (n = 177) moderately adequate and 9.4% (n = 32) inadequate. (Fig. 1) The average mean value was 11.48 ± 2.165. (Table 5) The correlation between fall knowledge, attitude of fall and awareness of fall risk factors were highly signi cant at p0.0001 with 95% CI. (Table 5)

Discussion
Fall in hospitalized patients is almost always preventable (10,11). Nurses with adequate knowledge and awareness on fall and its risk factors, are anticipated to bring about be a signi cant reduction in the prevalence of fall occurrence and positive in uence on fall among hospitalized patients (12). In our present study, 43.7% of nurses had previous patient fall experience which is similar to that reported by various studies (13,14). This is much higher than that reported by Kim et al (15). These differences may be due to nature of hospital infrastructure, years of nursing training program and difference in patient pro les.
Despite the fact that majority of the participants (71.7%) reported "received fall prevention education", only 15.6% had adequate level of knowledge which was lower when compared with the study reported by Kim et al (15), where 85.7% of nurses had high level of knowledge. Similar to our study, Laing et al (16) reported a lower level of knowledge among health workers about fall. In our study majority of the nurses had working experience of less than 2 years hence low level of knowledge regarding a complex multi factorial event like fall can be attributed.
In the assessment of knowledge session of the questionnaire statements pertaining to diseases condition, treatment related and medications related to fall as expressed by the participants represented lowest of all score similar with a previous studies (15,16). This could be attributed to not incorporating multidisciplinary evidenced based training on fall with new perspective. In India, it is a harsh reality that many hospitals neither have standard policies and procedures nor training programs on falls and its prevention. Laing et al (16) revealed that knowledge and skills of nurses related to fall and its prevention was improved after the training con rmed the need for evidence based training. Hence, introduction of a care bundle approach frequent in-services and focus groups may enhance nurses learning and improve clinical outcomes.
This study revealed majority 57.2% had favorable attitude towards fall which supports the study by Kim CG et al (14) where the attitude level of nurses was 77.2% positive on fall. This may be due to the social and cultural empathy incorporated in training. Contradictory results have been shown in various other studies (13,14,17). This may be due to difference in nature of study participants (students, workers)..
However, the potential gaps in awareness of fall risk factors may be addressed through developing nurse sensitive, context-speci c fall-prevention clinical guidelines for practice in India.
In our study 52.2% had moderately adequate awareness on fall risk factors .In contrast 60% of health care professionals including nurses had little or some awareness on fall risk factors in a study (18,19). Therefore, an onsite training program on awareness of fall risk factors designed for nurses is crucial and need of the hour in order to help them identify the most important risk factors for falls and translate the knowledge into practice. Majority of the participants (66.1%) expressed need for fall preventive education in this study this achieved through developing multifactorial, multidisciplinary fall preventive educational program and introducing bundle approach on fall.
The years of experience in nursing showed both strong association and positive relationship with level of knowledge. This implies that the knowledge improves as they gain more working experience because they obtain more information and hands on experience. The attitude of nurses towards fall had strong associations with age, gender, educational quali cation and experience in nursing. This implies that as their experience in nursing care increases with education and patient care the more the positive attitude they develop on fall and it preventive measure.
Interestingly, our study also showed a strong correlation between knowledge, attitude and awareness of fall preventive measures with each other. This is supported by several studies as well (14,15,16,20). This shows that continued medical education and training of nurses is required to bring about an overall change in fall incidents in hospitalized patients.

Conclusion
In our study, it is evident that there is a void which has to be lled to improve the knowledge, attitude and awareness on fall and its risk factors .There is a need for extensive education and holistic, multifactorial and interdisciplinary training program to be undertaken through various health care organization including governmental and non-governmental organizations regarding fall and risk factors of fall to reduce fall occurrence thereby ensuring patient safety.

Declarations
Ethics approval and consent to participate: Institutional Review Board (IRB) Approval has been obtained prior to start of the study (Panimalar Medical College Hospital & Research Institute IRB #1/2020/003). Informed Consent has been obtained from all the participants of the study.
-Consent for publication: All authors provided their consent for publication of this manuscript.
-Availability of data and material: The data used to support the ndings of this study are available from the corresponding author upon request.
-Competing interests: "All the authors declare no con ict of interest."