Date of Award

Spring 5-26-2022

Document Type

Doctor of Nursing Practice Final Manuscript

Degree Name

Doctor of Nursing Practice



First Advisor

Brenda Boone PhD RN


Purpose: The purpose of this project was to implement an RN nursing staff education on the fall risk assessment tool in effort to decrease falls on one adult locked inpatient psychiatric unit. The assumption was that an educational review of the fall risk variables for inpatient psychiatric patients and subsequent initiation of a fall risk care plan would lead to decreased falls.

Background: A fall can be defined as a sudden unintentional change in position causing an individual to descend to a lower level or onto an object, the floor or ground, or another surface with or without injury. Review of over 24,000 fatal falls has shown a cost of over $3 billion in healthcare for medically treated nonfatal falls with injuries. Incidentally, fall rates are higher among women than men.

Method: The Eight “A”s EBP model was used for this project. Unit setting: One adult locked inpatient psychiatric unit. Participants: Assigned RNs on the unit. Intervention: Education of fall risk factors and the fall risk assessment tool. This education was conducted on each of three shifts. The education included review of fall risk assessment tool and fall risk factors. Outcome measure: Number of falls on the adult locked inpatient psychiatric unit.

Result: Three months post intervention, there were fewer falls after the education on fall risk factors and the fall risk assessment tool.

Evaluation: Several factors may have impacted these results. The RNs were knowledgeable of the falls on their unit. During the educational time, the unit also had COVID patients and short staffing due to some RNs being out on leave. The reduction in falls may be attributed to a heightened awareness of the importance of assessing falls and subsequently implementing the fall risk plan of care after this educational program was discussed on the unit.

Implications for Clinical Practice: Repeating this educational process in six months may help evaluate whether a second educational intervention on the fall risk assessment tool will continue the downward trend in falls on this locked inpatient psychiatric unit.

Keywords: falls, fall risk, fall risk assessment tools, falls in psychiatry

Included in

Nursing Commons