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  1. Dykes, Patricia C. DNSc, RN
  2. Carroll, Diane L. PhD, RN, APRN, FAAN
  3. Hurley, Ann C. DNSc, RN, FAAN
  4. Benoit, Angela BS
  5. Middleton, Blackford MD, MPH, MSc


Objective: Obtain the views of nurses and assistants as to why patients in acute care hospitals fall.


Background: Despite a large quantitative evidence base for guiding fall risk assessment and not needing highly technical, scarce, or expensive equipment to prevent falls, falls are serious problems in hospitals.


Methods: Basic content analysis methods were used to interpret descriptive data from 4 focus groups with nurses (n = 23) and 4 with assistants (n = 19). A 2-person consensus approach was used for analysis.


Results: Positive and negative components of 6 concepts-patient report, information access, signage, environment, teamwork, and involving patient/family-formed 2 core categories: knowledge/ communication and capability/actions that are facilitators or barriers, respectively, to preventing falls.


Conclusion: Two conditions are required to reduce patient falls. A patient care plan including current and accurate fall risk status with associated tailored and feasible interventions needs to be easily and immediately accessible to all stakeholders (entire healthcare team, patients, and family). Second, stakeholders must use that information plus their own knowledge and skills and patient and hospital resources to carry out the plan.