Running Head: RESEARCH PROPOSAL: PART 2 1
Research Proposal: Part 2
Valerie Vick
UIN # L29354112
Liberty University
RESEARCH PROPOSAL: PART 2 2
Abstract
The consistency of falls being a National Patient Safety Goal (NPSG) are congruent to falls still
being a frequent occurrence within the healthcare setting. The CDC reported in 2016 that the
costs of injuries from falls are $31billion annually. Two-thirds of that cost is attributed to
hospital costs. The growing concern and prevalence of falls has gained attention from
researchers seeking to find, not only exactly what factors are intrinsic or extrinsic, but what can
be learned or changed to reduce its frequency of incidence. Since most falls are unanticipated
and are rarely observed, most research from this retrospective reporting has led to documenting
and preventing the intrinsic (e.g. psychological, physiological conditions) factors. This has often
led to the overlooked extrinsic (e.g. environmental) factors that surround each fall incident. This
paper will discuss the research findings of 3 different studies that considered the environmental
and hospital design features and the impact that it has on the prevalence of falls or its
contribution as a fall risk.
Research Proposal: Part 2
RESEARCH PROPOSAL: PART 2 3
The Center for Health Design: Study 1
The Center for Health Design and Coalition for Health Environments Research (CHER)
joined together to research the physical environment surrounding falls. Since falls are
multimodal and the factors involved are based on a combination of different factors and
circumstances, they realized that their framework needed to be representative of these as well.
Their approach was to examine the falls risk from the Lawton and Nahemow’s competence
model. The factors are characterized by the equation B=f (P, E, (PxE)). B is behavior, or falls, P
is the person (intrinsic factors), E is the environment (extrinsic factors), and PxE is the
interaction between the environment and the person. In order to have an influence on B (falls),
there would be a need to impact all the elements of P and E. As environmental factors was of
most concern, their focus was entirely on the E factor. Environmental factors can be
multifactorial and can involve lighting, flooring, footwear, room layout, or having single-patient
rooms.
Layout changes can be challenging and their modification too costly, making the impact
of spatial layout difficult to study. Interior features within the environment can be more easily
modified without mounting costs. Interior features can include furniture and its placement, the
presence of handrails and their location, and types of flooring. These have been studied and
have been easily altered when these factors interfered with a having safe environment. What this
report found was that furniture should be positioned so that it does not become an obstacle and
rooms should permit clear movement within the room. The type of flooring was not a factor in
fall risk, however, the type of floor finish is. High-gloss surfaces should be avoided as it causes
a glare can contribute to a fall-risk environment The substantial research on the lack of handrails
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and other assistive devices along walls in the home can be attributed to a fall risk, but no
research linked the presence or absence of them in the health care environment to fall rates.
Sensory systems that can impact a patient’s risk of falls. With these conditions being
expected in the health care setting, research indicates the presence of night lights and call bells to
be an expected feature in design plans. When background noise levels exceeded 30 decibels,
there was more sleep disturbance, which resulted in increased drowsiness. Tis a factor that could
increase fall risks, however, there were no studies that went further to explore noise factors on
fall rates.
Use of the environment focuses on how wheelchairs or personal furnishings, which
interface with the designed environment, contribute to human experience. Based on the Johns
Hopkins Fall Risk Assessment Tool, if a patient has been identified as a high fall risk, that patient
should be moved to a room which provides the best visual access to the nursing station[Joh17].
Transfer-related falls were studied and the only suggestion was to use different size wheelchairs
to accommodate different sizes of the population (for youths and adults).
The hope was that by the analysis of just E (environment), design teams would be better
able to incorporate intrinsic (P) and interactional (PxE) factors to explore both fall risk and
intervention strategies. However, based on this report, most of its research was multimodal,
making it problematic to know the particular impact environmental factors played in reducing
falls and injury from falls[Gul08].
The Center for Health Design: Study 2
The Center of Health Design teamed up with The Facilities Guidelines Institute this time
to examine the characteristics of the environment, once it is built, to look more at environment-
in-use variables. They wanted to link the actual environmental features with differences in fall
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rates. In order to accomplish this, they identified what factor in the patients’ rooms were related
to greater fall risks.
They used data assessed from Gulwadi and Calkins (2008) and used the Falls
Environment Evaluation Tool (FEET) to assess over 40 features of the patient’s room. A
significant portion of falls took place in the bathroom. There was however, a decrease in falls if
there was not a shared bathroom between two patients. More falls occurred when the bathroom
was on the headwall than on the footwall, leading to believe the cause was the decreased
visibility of the bathroom from a sitting position on the center of the bed. Also, when the toilet
was across from the door, preventing having a continuous handrail to the toilet, more falls
occurred. Having two grab bars on either side of the toilet was associated with having fewer
falls.
Patterns in the flooring were identified as having an effect on the occurrence of falls.
This study described patterns as either small (less than 1 inch wide), medium (1 to 6 inches
wide), or large (greater than 6 inches). The rooms which had medium sized patterns were
associated with the most significant numbers of falls. When tile flooring was used instead of
linoleum, there was a decrease in the number of falls and 10 times less falls when tile was used
in bathrooms.
The unit’s staff work location was studied in all 12 hospitals. They looked at the
visibility from the upper third of the bed to these work locations and found that falls were higher
when there was direct visibility. This surprising finding was contributed to higher-risk fall
patients being placed in these locations. Another feature that was also assessed in the design of
the rooms was the presence or absence of family areas. When there was a space dedicated for
families, there were half as many falls.
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Noise was previously studied by Gulwadi and Calkins (2008), but only in regards to
decibels. This study focused more on alarms and overhead paging by hospital staff and saw this
as a factor that increased falls.
This study revealed many future design recommendations for hospitals. They would be
to dedicate areas within the rooms for families, choose flooring appropriately, placing toilets
along the side walls of bathrooms where grab bars can be on both sides, and looking more
closely at bathroom door openings and bathroom location within the rooms[Cal12].
National Patient Safety Foundation
The National Patient Safety Foundation awarded a grant to Debajyoti Pati of Texas Tech
University to lead a research study the physical design of the hospital room and bathroom and
how it contributed to falls. The enlisted the help of human subjects to test mock physical spaces
and be assessed using the worst case scenarios that have the most potential for falls. The
subjects’ activities were recorded and were closely examined by health care designers and
registered nurses.
The motion capture records detailed information about the movement of the body and
capture the underlying joint locations. They were able to gather information about how smooth
the subjects’ movements were while performing activities of daily living within the hospital
bathroom and bed. Movements contributing to a fall involved postural changes like pulling,
turning, or pulling when they were trying to maneuver to the bathroom and get around objects.
When there was an increase in these movements, indicating the beginning of a fall, it was called
the “jerk trajectory”. These movements were heightened in doorways, around the toilet,
intravenous poles and grab bars.
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This study was able to pinpoint specific postural changes that were similar in all fall
scenarios. The top postures seen in fall events were grabbing, pulling, turning, and pushing.
These changes in postures occurred when navigating through doorways, interacting with the
door, trying to find ample space for turns, locating grab bars, obstructing pathways from tray
tables, and the location of the toilet, its seat height and its’ fixtures. When the relationship
between falls and the intrinsic, environmental, and postural changes were examined together, the
postural changes remained significant. Since these postural changes occurred in areas that could
use modifications, researchers were able to determine that hospital design should be centered on
more appropriate postures in these areas and be given the most consideration. Some
recommendations are to design bathrooms that reduce the need for turning around the toilet, sink,
and doors; avoid swinging doors in the bathroom and instead use sliding doors; design wider
door openings that provide accommodations for IV poles. The author does note that these
recommendations need further assessment and research and should be considered hypotheses
only[Pti17].
Conclusion and Future Study
In light of the studies reviewed, there is a need to conduct more studies based on the
significant findings from these studies. Based on the information gathered from these studies,
the bathroom has been an area of great concern, where these studies recommended modifications
to the bathroom doors. Furthermore, my hypothesis remains that patient safety will improve and
falls will be decreased after the modification of the bathroom door to increase the width of the
opening.
References
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Calkins, M., Biddle, S., & Biesan, O. (2012). Contribution of the designed environment to fall
risk in hospitals. Concord: The Center for Health Design. Retrieved from
www.healthdesign.org
Gulwadi, G., & Calkins, M. (2008). The impact of healthcare environmental design on patient
falls. Concord: The Center of Health Design. Retrieved from www.healthdesign.org
Johns Hopkins Medicine. (2017, November 2). Fall Risk Assessment. Retrieved from Institue fo
Johns Hopkins Nursing:
https://www.hopkinsmedicine.org/institute_nursing/models_tools/fall_risk.html
Pati, D. V., Cloutier, A., Yang, J., Harvey, T., & Lee, J. (2017, February). Physical design factors
contributing to patient falls. Journal of Patient Safety.
doi:10.1097/PTS.000000000000033
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