A too-common scenario.
Joe opens his eyes and looks through the window of his hospital room. He has always been early to rise. Even at age 82, he can’t shake the habits he learned when he was young.
“I’m woozy again,” Joe thinks as he sits up in bed. His medication sometimes makes him feel that way. Joe presses the call light so a nurse can help him to the bathroom. The nurses have been reminding him to do that so he won’t fall.
Then he reconsiders. “I can make it on my own. I don’t want to bother the nurses. They need to help the patients who really need it.” Joe moves to the edge of his bed. His walker isn’t nearby, but he urgently needs to reach the bathroom. Still dizzy, Joe holds onto the bed for a moment to keep from falling forward. After a moment, he manages to stand up and walk to the bathroom. As he enters the room, his dizziness returns, and his legs suddenly feel weak. A feeling of dread washes over Joe as he begins to fall…
Nurse Smith starts her rounds and is looking forward to seeing Joe. He is always up early to greet her with a smile and a joke. As she opens the door to his room, she sees him entering his bathroom without his walker. She moves quickly toward him, but he suddenly sways forward. She knows he is going to fall. Reacting immediately, she grabs him by the torso to stop him from falling onto the bathroom floor. Joe grasps at her shoulders to steady himself, putting most of his weight onto her back and arms. Despite her smaller size, she successfully helps Joe to the toilet, then calls for help and a wheelchair.
Nurse Smith feels relieved that Joe is safe. “He might have hit his head on the toilet,” she thinks. However, she now feels a sharp pain in her lower back.
This vignette, while invented, may seem familiar to many nurses, since it captures common elements of assisted-fall scenarios that occur in hospitals across the country. In this scenario, Joe, who feels capable despite his advanced age and health status, decides that he can walk to the bathroom without waiting for assistance and without using his mobility aid. Nurse Smith reacts quickly by using her body to attempt to break or minimize the impact of Joe’s fall by slowing his descent and helping him to the toilet. In this moment, she considers only the risk of injury to the patient, injuring herself in the process.
Factors that make assisted falls more likely.
Situations like the one described above often lead to occupational injuries in staff members. Previous research has shown that even though there is no safe way to assist a falling patient, medical staff, including nurses, continue to do so. To understand more about why nurses assist falling patients (even when it could result in personal injury), first we must understand what leads to assisted falls. In our November 2023 article, “What Health Care Staff Who Experienced Assisted Patient Falls Can Teach Us: Implications for Fall and Fall Injury Risk,” we described results from our quality improvement project aimed at identifying common contributory factors and characteristics of assisted falls. We also looked at nurses’ experiences with assisted falls and why they choose to intervene with falling patients.
What drives nurses to assist falling patients?
We conducted this work as part of a Department of Veterans Affairs Patient Safety Center of Inquiry in Tampa, FL. In our interviews with nurses, they described some important reasons that they have assisted falling patients in the past and, in some cases, would assist a falling patient in the future. The most common reasons given included:
- A nurse may judge that the patient will sustain a major injury or even die if the nurse does not slow or break that patient’s fall.
- Nurses may have misconceptions that there are safe ways to assist falls because they have received training or education on using “ergonomic techniques” to slow or break patient falls (such as positioning close to the patient to avoid reaching, using their body to brace the patient, keeping the back straight, or guiding the patient’s descent).
- A nurse may judge that a falling patient weighs less than they, the nurse, do and may feel that they can safely slow or break that patient’s fall.
Nurses feel they have a ‘duty to assist’ falling patients.
Regardless of the reason that nurses have for assisting specific patient falls, all the nurses we interviewed felt like they had a “duty to assist.” As medical anthropologists working for a VA patient safety center, we wanted to better understand nurses’ “duty to assist” and what that might mean not only for patient safety, but occupational health and safety as well. For some of the nurses we interviewed, the sense of duty to the patient felt like a moral obligation, a personal core value, and/or a general instinct to protect others.
Understanding ‘duty to assist’ as a mental model.
The “duty to assist” is an example of the psychological concept of a “mental model.” A mental model is someone’s internal understanding of “cause” and “effect.” They are personal algorithms that help people make decisions and solve problems. For example, a nurse’s training and education, the culture of safety at their facility and on their unit, past experiences, and personal values can contribute to their approaches to patient care and safety.
It was eye-opening to learn from the nurses we interviewed that they often share a “duty to assist” mental model—an overriding desire to protect patients from injury even at the expense of their own personal safety. This was true even of nurses who had been injured in the past while assisting a fall and who understood the risks personally. For example, a common belief was that if the nurse had not assisted the falling patient (cause), that patient might have sustained a major injury or even died (effect).
The “duty to assist” mental model is a substantial driver for assisted falls and merits additional reflection. Furthermore, patients also make decisions based on their own mental models. In our vignette, for example, Joe is operating from a “self-efficacy” mental model when he decides he does not need to call a nurse or use his walker. Like many patients, Joe wants to do things independently even if he risks his safety. Nurse Smith makes a split-second decision based on her “duty to assist” mental model that tells her Joe is falling (cause) and therefore Joe will be hurt (effect), believing that if she uses ergonomic techniques to safely break the fall (cause), Joe will be safe (effect). Her misconception that she can safely assist Joe using ergonomic techniques may create a false sense that assisting Joe’s fall is not a risk.
Minimizing patient and staff injury risk through fall injury prevention strategies.
Many nurses struggle to balance the idea of a “duty to assist” and the reality that it is not safe to assist falling patients. Mental models, including the “duty to assist,” are difficult to change. For that reason, we believe that minimizing patient and staff injury risk when a fall does happen is critical. A focus on fall injury prevention strategies, such as securing the environment, is one way to do this.
It is critical for nurses to understand that there is no safe way to assist a falling patient even if ergonomic techniques are used, even if the patient weighs less than the nurse, and even if a nurse has safely assisted a falling patient before. Finally, we believe that more research on the drivers and outcomes of assisted falls is warranted. There is some evidence to suggest that assisting falls, while decreasing patient injury risk, increases staff injury risk—an uncomfortable tradeoff that raises important ethical questions.
We invite you to consider some of the questions raised by our work: What shapes morality and ethics in nursing and how do such concepts affect reasoning, problem-solving, and decision-making in practice? Could a better understanding of these constructs help health care organizations design policy and procedures that are sensitive to shared causal beliefs?
Margeaux Chavez, MA, MPH, CPH, and Sarah E. Bradley, PhD, MPH, CPH, are qualitative health systems researchers working for the Department of Veterans Affairs, Veterans Health Administration.
I agree that as a nurse, our attempts to prevent may be lead by our “duty to assist” but also think of it as “instinctual act” as we would as mother to a child, or a stranger helping when someone else is struggling. To me a more disturbing subject is barely mentioned in this article. For thirty years I have felt the need be duty bound to facilities or units to be prevention motivated and this notion that we can prevent all falls. But why and where did this “duty to assist” begin other than we really do not wish to see our patients injuries. Cost! In the background of my instinctual duty to assist, I have statements and policies pushing forward in my brain. Such as “we will have to pay for any injuries”, “we can be sued”, “falls lower our accreditation status”, ” “Medicare will reduce hospital revenue” and on a smaller scale “our unit will get gift certificates if we have no falls this month”. No falls is competitive! Or how about “sorry we do not have or we have budget limit on how many staff we can provide”. A lack of support from peers and administration when you are injured may be negligent. Another cost. That is blatantly a facility/unit cultural mistake. Leading to less reporting or the question of assisted falls being reported as a fall. Yes, we could go on about this. I do not believe we will remove the instinctual sense of attempting to prevent injury, pain or a death. There have been wonderful strides made in evidence based fall prevention in my career. Let’s take it up a notch, do not just figure out why so many of us have a moral or instinctual sense to help and how we do not consider the possibility may become the injured party in this situation. We should also figure why we must have the other voices in our heads about duty saying “this fall is going to cost us a lot of money”.