To: Director of Nursing Blodgett Hospital

From: Kassie Herp

Date: June 29, 2015
Subject: Patient and Staff Safety, Fall and Injury incidence. Interview Research Report
This document contains interviews that have been conducted to show the need for a standard of
education on patient and staff safety with ambulating and fall risk patients for all nursing staff.
If you have any questions, please feel free to contact me via email at kassieherp@gmail.com.

Interviews Research Report: Patient Falls and Staff Education

Kassie Herp
Ferris State University
June 26, 2015
Submitted to: Director of Nursing Blodgett Hospital

Abstract
This document contains information about the incidence of fall risks, staff education on fall risks
a safety, and ways to improve the problems. With these in mind, I interviewed three staff on
some questions about their education and the incidence of falls. With this information, the plan is
to revise staff education to better protect the patients and the staff members from harm

Introduction
From personal experience, both in work and in school, there is evidence that there is a need to
educate more on education for staff, more specifically, the nursing staff to promote safety for
patients and staff. There tends to be either a lack of knowledge, withdraw or enough time to
adequately assess patients. This leads to complications for staff and the patients, with fall
incidence and transfer related injuries to the staff. After interviewing three different staff and
gaining their knowledge on the matter, the hope is to revise policies and procedures to better
protect the staff and patients.
The focus on this research is to gain insight on patient falls, staff safety and education on these
aspects in the health care field.
Research Method
In order to gain first hand insight on this problem, three interviews were conducted by employees
of various jobs and ranks. Each of the interviewees were asked to participate and accepted the
invitation. These interviews were conducted on site, during non-working hours in mid-June
2015. The questions that were asked related to when the staff were educated on patient and staff
safety and falls, the incidence of falls, and if they though the falls were preventable (see
appendix).
Results
Staff orientation plays a very important role for education on safety for the staff and the patients.
To gain better insight on this subject, I asked the Nurse Manager of 3H Neuro/Spine Unit at
Blodgett Hospital, Val Tumbleson, to explain the orientation for the staff. According to Val, her
staff on orientation to the unit are to shadow Physical Therapy for 4-6 hours on their first two
days to learn how to transfer patients and protect themselves. The reason being that physical
therapists are the experts on transferring patients and the safest way to do so for both patient and
staff (personal communication, June 22, 2015). She indicated that because their floor recovers
spinal surgeries, it is very important to her that her staff know how to properly ambulate the
patients, to avoid complications and falls. Val also said that her staff receive yearly education on
patient safety and staff safety when it comes to ambulation. Val has a greater concern for her
staff and patients, because they are prone to more falls than other units because of their patients
situations. Val also said that, as the nurse manager she continually checks bed alarm response
time to make sure that the staff are running to the bed alarm to ensure patient safety from falls.
Education is just as important as bed alarms.
An interview was also conducted with the Patient Transport Educator for Blodgett and
Butterworth, William VanderZouwen. He also explained to me the orientation and training
process for his employees and their yearly education for patient safety and staff safety. He stated
that during his staff orientation, he goes over gait belt safety, walker safety and how to use the
equipment with all of the new staff (personal communication, June 24, 2015). William states that
before the staff are allowed to transport on their own, they need to be checked off, to make sure
that they meet all the expectations their job requires. William also stated that his staff are
required to go to an annual education day, where his staff are walked through patient transfers for

specific limitations that are encountered in the hospital with physical therapy. Here, the physical
therapists demonstrate the technique, watch the staff perform the technique and check them off.
William states that this annual education has helped improve safety of his staff as well as the
patients.
An interview was also conducted with Kristin Nesbit, a Registered Nurse in the ER at Metro
Health Hospital. Kristin was asked about her orientation to her job and her continued education
(personal communication, June 25,2015). Kristin stated that during orientation she was educated
on personal safety with proper techniques for herself and how to move and help patients
ambulate, while ensuring she is not injuring herself. She also stated that her continued education
is more geared toward the emergency nursing aspect, rather than patient safety. Kristin also
stated that majority of the time, they ask the patients to stay in the stretcher or bed and not get up
without help. Kristin also stated that majority of the time with how long the patients are in the
ER and with their presenting symptoms, they dont have as many incidents of falls with the
patients.
Discussion
In summary of the interviews, from the information that was provided I think there is a deficit
that is noted through education on patient and staff safety. Every nursing job is different because
of their area of expertise. For Val, her area of expertise is spine and neuro patients and for Kristin
it is ER. The daily patient encounters are very different on both sides. This can cause room for
error, if you will, on the education standard for all of nursing. This information can be used to
help come up with a standard of education on all of nursing, to protect patients and staff.
Conclusion
In conclusion, we see there is a discrepancy in the education standard. There will need to be
more interviews conducted with other nurse managers, more evidence collected, showing the
need for the education standard. Overall, based on the three interviews conducted, there is an
apparent issue of universal education. With the same standard for all staff, safety of patients and
staff could be promoted on a bigger basis and monitored better.

Appendix
Val Tumbleson
Do you feel like your falls are preventable falls?
Most of the time the falls are due to a confused patient. We put in all the necessary measures to
keep the a patient safe, such as bed alarm and place patient in a room close to the front desk.
Majority of the time we are on top of the bed alarm and my staff can be in there every 10 minutes
attending to the bed alarm. But most of the time the falls happen because the patient is anxious
and gets up with out help. Also, the falls are not falls, more so they are staff assisting the patient
to the floor which is considered a fall. We haven't had a big fall in awhile, but the last one I can
remember is we had a very confused and anxious patient that was on a bed alarm and we were in
turning the alarm off every 10 minutes, and during on of those incidents a staff member forgot to
turn the bed alarm back on and the patient fell to his knees on the ground, Luckily the patient
wasn't hurt.
When does your staff get education on back safety and falls?
During orientation, my staff starts off with shadowing a physical therapist for 4-6 hours for the
first day or two, to orient them to how we move and ambulate patients as well as the proper body
mechanics to protect themselves. The reason we have them shadow physical therapy is because
they understand how the whole body moves as a whole and have a greater understanding of how
each area operates in conjunction to another. Here my staff learn gait belt use, walker use, log
roll technique, learn about spinal limitations and braces. As for continued education, my staff are
required to do 16 hours of continued education every year. I also make sure to monitor bed alarm
response time and call light response time, because those are major factors that contribute to
falls. I also will round to make sure that we are properly using fall risks identification and
precautions when needed.
William VanderZouwen
How do your staff get their education on back safety and fall prevention?
when our staff are hired in I go over a tutorial on how to use the equipment such as gait belts,
walker, wheelchair, lift and stretcher. After the tutorial our staff are trained with our preceptors
for 4 to 6 weeks where they will learn more specific transfers such as log roll, pull over, up with
1, up with 2 and so forth. We then at the end of their training walk with them on different runs
and watch them perform the skills to make sure they are able to do them on their own. We have
to see them do a pull over, ambulate the patient with a gait belt and walker, and see them use a
wheelchair and a stretcher. After the staff are checked off we have them attend an annual
education day, where we have teamed up with physical therapists who show them the proper
technique with ambulating patients in situations such as open heart surgery, back surgery, knee
and hip replacements, stroke or one sided weakness, lifts, pull overs, and gait belt use.

Have you seen an improvement in safety with your staff and patients?
We have seen an improvement, every year it seems to be that way. We notice that our staff
become rehearsed in the role and don't take the time to place the proper precautions for
themselves. We notice that after the education day there seems to be less staff injury. As for
patients safety, more often than not, our staff are doing what they have been taught. There are
some situations where the staff members should have stepped up and said they were
uncomfortable and wanted more people to help or didn't agree with the way the patient was
ambulating. It is a little difficult, because it seems that majority of the patient incidents we have
encountered, the nurse was there. In that case our staff has to report the incident even if they
were not the staff member assisting the patient.
Do you have falls in your department often?
We don't have falls in the department often. We have been fall free for about 6 months now.
When you do have a fall in the department, do you feel like it could have been prevented?
I do think that our situation is a little different in that aspect. In our department, the falls are
almost always from ambulating the a patient to a stretcher or wheelchair for a test or transport
throughout the hospital. In this case we are not the only ones there that are helping with the
ambulation. There is almost always a nurse or a tech there to help. I think in these instances the
my staff and the nursing staff are both to blame if there is a fall. One difficulty that is hard to deal
with in these situations, is the nursing staff assesses the patient on how well they can ambulate
and the assistance that they need. This makes it difficult because my staff are told how the patient
ambulates and has to go off from that information.
Kristin Nesbit
What kind of education did you as a nurse?
When I got my job as an ER nurse, I had to go through orientation where we were given tutorials
on gait belt use and walker use. However, since my orientation I haven't gotten much education
on this. Our education is based more on being a nurse in the er, triaging, how to run a code, and
how to handle traumas. In my job, we don't really run into this issue. Most of our patients stay in
their stretchers or chairs while they are being assessed by the nurse and doctor.