The Perceived Knowledge of Fall

Prevention in Nurses Working in

Acute Care Hospitals in China and
the United States
Wang, Lin RN, MMD∗; Zhang, Li RN, MMD†; Roe, Elizabeth RN, PhD‡;
Decker, Sally RN, PhD‡; Howard, Gwen MSA§; Luth, Angela RN, BSN§;
Marks, Kristine RN, MSN∥; Whitman, Brenda RN, MSN∥

Author Information

Journal of Patient Safety 18(2):p e580-e584, March 2022. |

DOI: 10.1097/PTS.0000000000000873

OPEN Metrics

Abstract

Objective
The aim of the study was to investigate the perceived
knowledge of fall prevention in nurses working in hospitals in
China and the United States.

Methods
A cross-sectional survey with 17 items was used to measure
perceived knowledge of fall prevention of nurses working in
hospitals in China and the United States.

Results
A total of 1442 nurses at 2 hospitals completed the survey in
China (90% return rate), and 260 nurses in 2 hospitals in the
United States (42% return rate) for a total sample size of
1702. Six items had means less than 4, indicating less
familiarity with these factors. These items included
assessment of vertigo and vestibular dysfunction, vision, foot
problems, balance and activity, cognitive changes, and
medications. In both countries, there was a difference in 2
units worked, with those working in maternal-child having a
lower perception of knowledge of fall prevention than those
employed on medical-surgical units. Of the 17 items, 11 were
significantly different between China and the United States, all
with the United States having higher perceived knowledge.

Conclusions
For both the United States and China, the perception of
knowledge of fall prevention was high. However, nurses from
both countries were less familiar with the items not commonly
included on fall risk tools, such as vertigo and vestibular
dysfunction, vision, foot problems, balance, and cognitive
changes. The findings have implications for practice and
education and suggest a need to include important factors
related to falls in education and intervention in both countries.

Falls are a serious international public health issue affecting individuals of any age. The World
Health Organization defines a fall as “an event which results in a person coming to rest
inadvertently on the ground or floor or other lower level.”1 According to the study on the global
burden of disease, 696,000 people died from falls in 2017.2

In China, falls are the second leading cause of injury and disease burden after road traffic
injuries3 with deaths and the burden of disease from falls primarily associated with older age (older
than 70 y).4 Furthermore, in China, the incidence of falls in hospitalized elderly patients is more
than twice that of the general elderly population.5 In Chinese hospitals, falls are the main safety
problem in elderly inpatients, and the incidence of falls in elderly patients in hospital can be as high
as 30%, accounting for approximately 40% of hospital adverse events.6

In the United States, more than 1 of 4 older people fall each year.7 In addition, hundreds of
thousands of patients fall in U.S. hospitals annually with 30% to 50% of these falls resulting in
injury.8 Statistics from 1263 hospitals in the United States indicates that adults on medical and
surgical units fall 3.56 times per 1000 patient days with 26.1% of falls resulting in patient
injuries.9 Falls are also a concern for younger patients. A study in 1 large multihospital healthcare
system in the United States found that there were 1.6 newborn infant falls per 10,000 births.10 A
survey of 26 hospitals in the United States reported that within a 6-month period, pediatric inpatient
fall rates ranged from 0.4 to 3.8 cases per 1000 patients.11 The consequences of falls are
manifold, including physical, psychological, social, economic, and sometimes even fatal
sequalae.12

In addition to causing significant health problems, falls are extremely costly. In China, the 25 million
falls experienced annually by 20 million of the elderly population exact direct medical costs of
approximately ¥5 billion (approximately U.S. $0.8 billion) and social costs of ¥60 to 80 billion (U.S.
$9.51–$12.68 billion).5 In 2015, the Centers for Disease Control and Prevention estimated the cost
of fall-related injuries in the United States at a total of more than 50 billion dollars annually; the
average hospital cost for a fall injury is approximately U.S. $34,000, with Medicare paying
approximately 78% of the costs of falling.13 Falls in hospitals not only threaten patients’ health but
also present care, quality, and safety issues. Preventing hospitalized patients from falling is an
urgent and lasting problem in countries all over the world. Every medical organization
internationally considers the incidence of falls as an important safety indicator. In China, the
Chinese Hospital Association has been making prevention and reduction of falls, one of its patient
safety goals since 2008. Other recommendations include special fall prevention committees to
study how to prevent the patient from falling in China.14 In the United States, the Joint
Commission recommends a series of actions to help each healthcare organization prevent falls and
fall injuries.7 Since October 2008, Medicare no longer reimburses acute care hospitals for the
costs of additional care required because of hospital-acquired injuries, such as falls.

Fall prevention in clinical practice is a complex undertaking that requires the collaboration of
multiple disciplines with nurses as the leaders in this initiative. In clinical practice, nurses are on the
frontline and are mainly responsible for the assessment of the risk of falls and health education of
the patients.15 This requires nurses to be equipped with knowledge and skills of fall prevention to
perform these roles effectively.

This study investigated and compared the status of perceived knowledge of fall prevention in
nurses working in acute care hospitals in China and the United States. The World Health
Organization reported that China has the largest fall-related disease burden in the world. China has
begun to study fall-related issues in the past 2 decades. However, the United States has been
focusing on the problem of falls and engaging in research programs about fall prevention since the
1970s. Although there has been a lot of research on this topic in the United States, falls, especially
in the acute care setting, are still an issue. The results of this study provide important information
for nurses in both China and the United States.

METHODS

Study Design
This was part of a larger study examining perception of safety culture of nurses in China and the
United States. After approval by the institutional review boards of the participating university and
hospitals in the United States and China, packets were prepared that contained the following: (1)
cover letter; (2) demographic information; (3) Safety Attitude Questionnaire; (4) fall prevention
knowledge questionnaire; and (5) adverse event reporting scenario. This article describes the
results of the fall prevention knowledge questionnaire.

Study Tools

Demographic Information

Demographic data that were collected included years of experience, education level, and unit
worked.

Fall Prevention Knowledge

Fall prevention knowledge was measured by a questionnaire designed by Gong and Chen.16 The
Fall Prevention Knowledge Questionnaire was originally written in Chinese and translated into
English and then back translated by 2 different Chinese authors. This questionnaire was developed
by the Chinese authors based on a review of literature and common components in fall risk
assessments to measure the knowledge, attitudes, and behaviors of clinical nurses on fall
prevention in hospitalized patients. The original questionnaire consisted of 3 parts with 42 items
regarding knowledge, attitudes, and behaviors. The 17 items that measured self-perceived
knowledge were used in this study. The items were rated on a 5-point Likert scale from strongly
unfamiliar to strongly familiar with a higher score indicating more familiarity. During development of
the tool, a presurvey was conducted with 35 clinical nurses to establish content validity and test-
retest reliability. The content validity of the questionnaire was confirmed by 10 experts. One week
later, 20 nurses of the previously mentioned 35 clinical nurses were surveyed using the same
questionnaire for repeated measurements, and the results were obtained from the 2 surveys. The
results showed that the retest reliability of the questionnaire was r = 0.840 (P < 0.01). It showed
that the stability of the entire questionnaire was good with an internal consistency coefficient of a
Cronbach α level of r = 0.87.

Data Collection
Packets of the questionnaires were distributed by nurse managers at the participating agencies via
the nurse’s mailbox on the unit. In China, 1600 packets were distributed to the 2 acute care
hospitals, and in the United States, 612 packets were distributed at the 2 agencies. A poster was
displayed in the unit break rooms asking for participation. The nurses were instructed via the cover
letter to complete the survey on their own time and place it in the locked box located in each unit
break room; the boxes were emptied every other day for 2 weeks by one of the coinvestigators.

RESULTS
A total of 1442 nurses at 2 different hospitals completed the survey in China (90% return rate) and
260 in 2 different hospitals in the United States (42% return rate). Overall, regarding education, the
most common educational level was Bachelor of Science in Nursing (57.9% overall; 58.5% in
China and 48.9% in the United States; no significant difference between the United States and
China). The second most common educational level was diploma with more nurses in China
(34.4%) with a diploma degree than in the United States (8%). There were more nurses educated
at the associate degree level in the United States (44.7%) than in China (3.7%). Overall, related to
work area, the most common unit worked was medical-surgical (55.8% overall; 58.3% in China;
38% in the United States), followed by maternal-child (13% overall; 12.5% in China; 15% in the
United States). For both countries, the mean year of work experience was 9.05 years, which was
similar in China (9.59 y) and the United States (9.65 y). The participants’ demographic
characteristics are presented in Table 1.

TABLE 1 - Demographic Characteristics

 United
China, n
Items States, n Total, n (%
(%)
(%)

Educational background
54 (3.7) 106 (44.7) 160 (9.6)
Associates
degree
Diploma 500 (34.4) 2 (0.8) 502 (30.2)
Bachelor 854 (58.5) 116 (48.9) 970 (57.9)
of Science
in Nursing
Master of 15 (1) 8 (3.3) 26 (1.5)
Science in
Nursing
Working area
Medical- 846 (58.3) 91 (38) 108 (6.4)
surgical
Critical 121 (8.3) 53 (22.1) 174 (10.3)
care
56 (3.9) 31 (12.9) 87 (5.1)
Emergency
department
Operating 87 (6) 21 (8.7) 108 (6.4)
room
Maternal- 181 (12.5) 36 (15) 217 (13)
child
Other 149 (10.3) 7 (2.9) 156 (9.2)
The questionnaire demonstrated adequate reliability with a Cronbach α level of r = 0.937 for
combined data (r = 0.934 for China and r = 0.949 for the United States). For the combined data, the
question with the highest mean was “Do you know which people are at high risk of falls?” (mean =
4.54, SD = 0.61). The item with the highest mean in the United States was “Do you know the
definition of a fall?” (mean = 4.67, SD = 0.53), which was ranked fourth in China (mean = 4.34, SD
= 0.68). The item with the highest mean in China was “Do you know which people are at high risk
of falls?” (mean = 4.52, SD = 0.61), which was ranked second in the United States (mean = 4.66,
SD = 0.60).

Overall, there were 6 items with means less than 4 (indicating a lower perceived knowledge): “Are
you familiar with the assessment of patients’ vertigo and vestibular dysfunction?” (mean = 3.38, SD
= 1.02); “Are you familiar with the assessment of patient’s vision?” (mean = 3.57, SD = 0.97); “Are
you familiar with the assessment of patient’s foot problems?” (mean = 3.61, SD = 0.95); “Are you
familiar with the assessment of patient’s balance and activity?” (mean = 3.83, SD = 0.93); “Are you
familiar with the assessment of cognitive changes in patient?” (mean = 3.91, SD = 0.88); and “Do
you know any medications that easily cause patients to fall?” (mean = 3.97, SD = 0.84). The
descriptive statistics for individual items are shown in Table 2.

TABLE 2 - Item Means and Differences Between

China and the United States

United
Overall China,
Items States,
Mean (SD) Mean (SD)
Mean (SD)

1. Do you 4.39 (0.67) 4.34 (0.68) 4.67 (0.53)

know the
definition of
a fall?
2. Are you 4.24 (0.83) 4.21 (0.80) 4.43 (0.95)
familiar with
the fall
prevention
assessment
tool currently
used?
3. Do you 4.54 (0.61) 4.52 (0.61) 4.66 (0.60)
know which
 United
Overall China,
Items States,
Mean (SD) Mean (SD)
Mean (SD)
people are
at high risk
of falls?
4. Do you 4.35 (0.74) 4.32 (0.74) 4.56 (0.72)
know when
the risk
factors of
falls should
be
assessed?
5. Do you 4.36 (0.67) 4.32 (0.67) 4.59 (0.66)
know what
the risk
factors of
falls in the
environment
are?
6. Are you 3.83 (0.93) 3.78 (0.91) 4.15 (0.96)
familiar with
the
assessment
of patient’s
balance and
activity?
7. Do you 3.97 (0.84) 3.90 (0.83) 4.44 (0.76)
know any
medications
that cause
patients to
fall?
8. Do you 4.05 (0.74) 4.01 (0.73) 4.36 (0.76)
know any
diseases
 United
Overall China,
Items States,
Mean (SD) Mean (SD)
Mean (SD)
that easily
cause
patients to
fall?
9. Are you 3.61 (0.95) 3.6 (0.91) 3.68 (1.1)
familiar with
the
assessment
of patient’s
foot
problems?
10. Are you 3.57 (0.97) 3.52 (0.95) 3.92 (0.99)
familiar with
the
assessment
of patient’s
vision?
11. Are you 3.38 (1.02) 3.34 (0.99) 3.65 (1.1)
familiar with
the
assessment
of patients’
vertigo and
vestibular
dysfunction?
12. Are you 4.10 (1.51) 4.12 (1.5) 4.05 (1.0)
familiar with
the
assessments
of the
patient’s
clothing and
 United
Overall China,
Items States,
Mean (SD) Mean (SD)
Mean (SD)
footwear
suitability?
13. Are you 3.91 (0.88) 3.83 (0.87) 4.4 (78)
familiar with
the
assessment
of cognitive
changes in
patient?
14. Are you 4.38 (0.70) 4.37 (0.69) 4.46 (0.77)
familiar with
the
intervention
of fall
prevention?
15. Do you 4.38 (0.74) 4.39 (0.72) 4.38 (0.87)
know how to
deal with
patients after
falls?
16. Are you 4.28 (0.85) 4.29 (0.84) 4.29 (92)
familiar with
the reporting
system of
falls?
17. Are you 4.25 (0.89) 4.26 (0.88) 4.24 (0.96)
familiar with
the reporting
process of
falls?
Total mean 4.09 (0.62) 4.06 (0.61) 4.28 (0.64)
 *Statistical differences at P < 0.05.

Of the 17 items, the means of 11 were significantly different between the United States and China,
all with the United States having higher means (see Table 2 for differences between the 2
countries). In addition, there was a significant difference between the United States and China with
the total mean. Item differences between the United States and China are seen in Table 2.

Overall, there were many similarities between the perceived knowledge of the nurses in China and
the United States; the items with the lowest and highest means were alike. To examine differences
in the perception of fall knowledge and demographic variables, the total score/mean was used. The
only significant difference was between perception of fall knowledge and unit worked. There was a
significant difference between the nurses working on medical-surgical units and maternal-child
units with the former indicating that they are more familiar with the items listed in the fall knowledge
questionnaire (F(5,1664) = 24.67, P = 0.000).

CONCLUSIONS
The findings of the study have several important implications for clinical practice both in China and
the United States. Although, overall, the perception of knowledge was high (most items scored as
familiar or extremely familiar), there were 6 items that scored less than a mean of 4 in both
countries, which would indicate that the nurses’ perception was less than familiar and revealing
areas that need further education. A recent systematic review of strategies to prevent falls in older
adults concluded that staff education is an important part of an effective fall prevention
program.17 A meta-analysis of fall prevention interventions only found small effects on fall
rates.18 Self-assessed knowledge of nurses in fall risk assessments is an important first step and
will vary by the specific needs of individual patients in the hospital that take into account the
differences in Asian and Western populations. Overall, the perceived knowledge of the nurses was
higher in the United States when compared with China. This may be because of the long-term
emphasis on fall prevention in the United States, which often includes mandatory continued
education. In the United States, fall prevention is often included in periodic education
competencies; this is not common in China. In this study, most areas that the nurses indicated that
they were familiar with were those frequently included on standard fall risk assessment scales in
both countries. Although 2 of the items that they felt more familiar with are commonly associated
with fall risk assessment tools for adults, such as the Morse Fall Scale19 (assessment of
medications and cognitive status), the other 4 items were known risk factors for falls but not
included in standard fall assessments (assessment of vertigo and vestibular dysfunction, vision,
foot problems, and balance and activity). This is consistent with research from China,16 which
indicated that nursing staff lacked the relevant knowledge of assessments on drugs, diseases that
easily cause patients to fall, patient’s vision, and vertigo and vestibular function. Dizziness and
vertigo are symptoms common to many health conditions and are often difficult to
manage.20 Research in Korea found that the probability of falls was increased by
dizziness/vertigo.21 A review of literature identified the need to provide a multidisciplinary
approach to assess vertigo in the risk for falls.22 This provides implications for education regarding
additional risk factors for falling that may not be included in traditional fall assessments. Although
these additional risk factors may be less applicable for the newborn and pediatric populations,
inpatient falls are significant in these populations, and it is important that risks for falls are
assessed. Findings from a study in the United States concluded that fall risk assessment tools and
prevention protocols in 26 major pediatric hospitals have not been standardized.23 An integrative
review of pediatric fall risk assessments found that the tools used are not reliable across institutions
and diverse populations.24 Further research on fall prevention and risk assessment is needed in
this population.

In addition, although there were not significant differences in the self-reported perception of
knowledge and the demographic characteristics of education and years of experience, there was a
difference in 2 of the units worked—medical-surgical and maternal-child with those employed on
maternal-child having a lower perception of knowledge. Gong and Chen16 found in their research
conducted in China that scores of knowledge, attitudes, and behaviors of clinical nurses in the
departments of medical and surgical were significantly higher than those of the clinical nurses in
the departments of gynecology, pediatrics, and neonates. Furthermore, research in the United
States has found that although falls may be prevalent on maternal-child units, knowledge of the
factors that put one at risk for falls may be different in these areas. One group of researchers
associated falls with maternal fatigue, rooming in, and encouraging breastfeeding as potential risk
factors.25 The Joint Commission in an advisory on safety called “Preventing Newborn Falls and
Drops” identified cesarean birth, use of pain medication, second or third postpartum night
(especially around midnight to early morning hours), and breastfeeding as potential risk
factors.26 They recommended strategies, such as developing an assessment tool, education,
rounding, promoting maternal rest, and developing signage as safety actions to consider. Although
falls do occur on these units, the knowledge of the nurses on the factors presented in the
questionnaire is reported as lower. This provides an area for further research and education.

It is also important to note that as research about fall prevention grows in Asian countries, it is
imperative that local issues are considered to ensure that research and programs implemented in
these countries are effective and relevant to the local context, people, and the health
system.27 Although falls in the hospital are serious issues in both China and the United States,
differences in the healthcare system and culture are relevant when considering strategies to
increase the knowledge of nurses regarding falls and decreasing the risk for falls. Although not
apparent in the routine fall risk assessments in the United States, the tool developed in China
identified vertigo and vestibular dysfunction, vision, foot problems, and balance, and activity as
important to the knowledge of falls, and these may want to be further tested in the United States.
Other differences in fall protocols may provide further areas of research including frequency of fall
assessments, strategies for fall education, and interventions to reduce falls.

There were several limitations to this study. The response rate was lower in the United States than
in China, which may be partially due to cultural differences but does make it difficult to compare the
results of the 2 countries. Furthermore, the questionnaire was used because it was applicable in
both countries, and although the reliability was adequate in this study, there is limited
documentation of previous reliability and validity. An additional limitation to this study is that actual
knowledge was not measured. Further research is needed regarding the actual knowledge of fall
risk, especially related to factors not normally associated with traditional fall risk assessment.
However, a second piece to this study not reported in this article included a fall scenario where
nurses selected the interventions that they would implement, which may more directly reflect
knowledge of fall protocol.

Based on the perceived knowledge of fall prevention in nurses in China and the United States,
further investigation and discussion of the attitudes and behaviors of fall prevention, education, and
interventions should be conducted internationally. This cooperation could provide unique
perspectives across populations and opportunities for nurses to learn from each other. It is
important that education regarding fall prevention be provided to nurses on an ongoing basis,
starting in initial nursing education. In the hospitals where this study took place, further education
focused on the areas not traditionally included in fall risk assessment scales is ongoing as a result
of this study.

REFERENCES
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at: https://www.who.int/news-room/fact-sheets/detail/falls. Accessed
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national age-sex-specific mortality for 282 causes of death in 195
countries and territories, 1980-2017: a systematic analysis for the
Global Burden of Disease Study 2017. Lancet. 2018;392:1736–1788.
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