An Analysis of the Patient Falls in the Nursing Homes

Topics: Nursing Home

St. Luke’s Nursing Care Home (SLNCH) is an institution offering nursing care for senior citizens aged above 65 who suffer various illnesses and require constant attention. The institution currently has a population of 35 resident patients and 20 nursing staff. The institution’s
management has experienced an increase in the number of patient falls, some of which have resulted in serious injuries rendering some of the patients nonambulatory. The rise in the number of patient falls has been attributed to an increased the size of the facility.

Consequently, the monitoring of the patients by the nurses became irregular hence the rise in patient falls. Although the number of nurses is still considered adequate for the present patient population, the addition extra space has greatly affected the time and speed of response to patients.

According to Staggers & Jennings (2009), change is an inevitable part of any organization that is expected to remain competitive in the constantly evolving challenges. Patient falls are categorized as one of the leading causes of both fatal and non fatal injuries in elderly
residents of the nursing home.

More than 20, 000 Americans die annually as a result of patient falls; most of these are elderly citizens aged above 65 years[Pel10]. The SLNCH needs to institute a change to ensure that the patients falls are eliminated in order to maintain its status as a reputable nursing care organization. This paper discusses the possible change process that can be adopted in SLNCH based on the Kotter’s 8-Step Change Model[ Kot15]

ldentification of Change

The management of SLNCH in recognition of the prevailing risk from patient falls has proposed to institute a change in the nursing duties.

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The management proposes to increase the the frequency of patient observation by decentralizing the nursing units. The expansion of the
facility increased the distance between the patients and the nurses. The decentralization of nursing stations will involve establishment of nursing Stations at all patient residences.

Alignment With Organization’s Values

SLNCH’s mission is to enhance comfort to elderly citizens and reduce risk of injury at all times by offering quality, timely, personalized, professional nursing care to elderly citizens. The decentralization of the nursing stations will greatly enhance the personalized care by ensuring that the nurses are in close proximity to the patients.

Outline of Change Model Steps for the Change

Step 1: Create a Sense of Urgency

The nurse leader will kickstart the change process by inviting the nurses to a meeting where they will be informed about the rising cases of patient falls since the facility underwent expansion. The nurse leader would point out that the patient population has not changed
significantly and that the present nurse to patient ratio is adequate to ensure efficient service. The nurse leader should proceed to alert the staff members that patient falls are a cause of both fatal and non fatal patient injuries, supporting the assertions using realistic data from the SLNCH or statistical data from national and state surveys. Similarly, the nurse leader would inform the staff about the extra costs incurred in the treatment of injuries emanating from patient falls. Patient falls that cause minor injuries cost an extra $3,500 to manage while serious injuries from patient falls might cost an additional $27,000 to treat which greatly erodes the instituion’s revenues|Bou12]. Additionally, there is a risk of litigation if a patient fall occurs due to negligence. The nursing manager would assure the nursing staff that he would not want the institution or any staff member to be summoned for negligence or bear an additional cost due to patient fall incidences. The nursing staff will recognize the seriousness of the situation and would thus be willing to undertake any changes that would shield the institution and themselves from additional costs.

Step 2: Build a Guiding Coalition

The nursing manager constitutes a steering committee made up of three employees to oversee the decentralization of the nursing stations. The three nurses form the guiding coalition and are given specific roles. The first one is responsible for coordinating the structural
rearrangements, the second one is charged with educating the other nurses about the change process and the third one is charged with coordinating the various departments involved in the change.

Step 3: Creating a Shared Vision

The nurse manager must convince the staff that they will benefit from the decentralization of the nursing stations. The nurse leader can effectively communicate the vision by ensuring that it is discussed in all departmental meetings and also written on the nurse notebooks. The nurse manager should also recognize that the patients are important for the success of the change and thus should design a strategy for informing and educating them.

Step 4; Gaining Buy-In

The pioneer team of the nurses will help the nurse leader to convince other staff members about the benefits that will emanate from implementing the change. The nurses, for example will be closer to the patients, and they will have to walk shorter distances to attend to the patients. Additionally, the decentralization will ensure that the nurses have a clearer line of vision on the patients and can respond adequately to nonambulatory patients.

Step 5: Enable Action by Removing Barriers

In the fifth step, the nurse leader should ensure that all the newly established nurse stations are adequately furmished with computers and other supplies required by nurses to discharge their duties efficiently. Similarly, an assistant nurse leader should be appointed for each
station to ensure timely supervision and decision making.

Step 6: Generate Short-Term Wins

On the first day of implementation, the newly appointed assistant nurse leaders will be provided with unique uniforms. The nurses will also have color coded headgear specific to each station to distinguish them. New stationery will also be issued on the day that the decentralization is executed.

Step 7: Maintain the Push

The newly appointed nurse supervisors at each decentralized nurse station will be expected to oversee the kickoff of the decentralization of nurse staions. They will guide the staff through the process and give regular progress reports to assess the success of the change. He
nurse leader will be in charge of the overall coordination of the decentralization. A regular appraisal of the project will help to identify challenges and come up with solutions. The staff will have to undergo continuous training to enhance their skills and ensure the success of the change. A change is a continuous process that is implemented over a period and requires regular and improvement[ Sta09].

Step 8: Hard Wire the Change

Finally, the change will become a culture in the organization as more patients get accustomed to the decentralized nurse stations. Similarly, the job descriptrions of the staff members will reflect a decentralization of the nurse stations. Additionally, staff recruitment will
be carried out based on the new system which will further enhance its entrenchment into the the SLNCH organizational culture. The nurse leader should begin collecting data for the incidences of patient falls which will analazed and communicated to the staff and the management.

The nurse leader, in consultation with the SLNCH management will initiate the decentralization of the nurse stations as a response to the rise in the number of patient falls. Nurses are in direct contact with patients and form the primery care officers. The nurse manager
is thus well placed to collect patient data and identify challenges in the delivery of nursing care. The funds for implementing the change would be provided by the Finance Officer. The change implementation will be overseen by the nurse manager and members of the guiding coalition. The progressive management will be overseen by the nurse leader with assistance from the nursing asSistant managers.


Patient falls are a serious issue in nursing home care for elderly citizens and is a leading cause of both fatal and non fatal injuries especially in nonambulatory patients. The occurrence of patient falls in nursing homes can be reduced through change in the nursing process. This paper
discussed the decentralization of nurse stations in SLNCH as a change to reduce the incidences and effects of patient falls. The Kotter’s 8-Step Change Model was applied in the description of the change process. Although the decentralization of nursing stations is expected to reduce the occurrence of patient falls in SLNCH, its effectiveness can only be determined by collection and analysis of data. continuous monitoring should be carried out to determine if another change should be instituted to complement the decentralization of nursing stations.


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  2. Reducing Patient Injuries from Falls. Cambridge, MA: Institute for Healthcare Improvement. Retrieved from Institute for Healthcare Improvement: International. (2015, August 1).
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An Analysis of the Patient Falls in the Nursing Homes. (2023, Mar 10). Retrieved from

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