Exploring the T.I.P.S. Fall Prevention Toolkit and Self-Efficacy of Staff on a Geropsychiatric Unit

Falls are adverse events for hospitalized patients that can impact the length of hospital stays, medical costs, and mortality (Noh et al., 2021). The World Health Organization ([WHO], 2021) reports that falls cause unintended injuries in older adults due to risk factors associated with environmental concerns, history of falls, and physical, sensory, and cognitive impairments. Patients with cognitive impairments, including Alzheimer’s and other types of dementia, are three times more likely to fall than the general older adult population (Beckwith, 2020). Due to the associated risk factors, a patient-specific fall prevention program may be beneficial to healthcare staff to promote fall prevention in the cognitively impaired population.

Geropsychiatric patients are at greater risk for falls as compared to other hospitalized patients. The incidence of falls in geropsychiatric patients is 11.7, compared to 8.9, falls per 1,000 bed-days, which may result from psychological disorders that impair cognition (Hakvoort et al., 2021; Suga et al., 2021). Increased falls among geropsychiatric patients may also be due to medications that impair cognition in older adult patients (Geskey et al., 2023). Polypharmacy, or the use of multiple drugs, can increase fall risks among older adults (Alharkan et al., 2023). Alharkan et al. (2023) demonstrated that each medication added to a patient’s regimen increases their fall risk by 14%, regardless of the medication’s drug class. Psychotropic polypharmacy is a unique concern for psychiatric inpatients. The incidence of falls is greater in psychiatric inpatients, as compared to non-psychiatric units, due to psychotropic medications and their side effects, over-activity, and confusion (Wong et al., 2021).

Evidence-based research can guide healthcare personnel in prevention of falls among geropsychiatric patients. Multiple fall risk assessment tools are available. The Tailoring Interventions for Patient Safety (T.I.P.S.) toolkit has been identified as an effective evidence-based fall prevention program becoming a standard in reducing fall and injury rates (Dykes et al., 2020). This article describes implementation of the T.I.P.S. toolkit as a new fall prevention program at one community hospital geropsychiatric unit to determine its effect on the self-efficacy of licensed and unlicensed staff among the geropsychiatric unit.

Background

Significance of Falls in Older Adults
Falls are the second leading cause of unintentional injury deaths, with an estimated 684,000 people dying globally from falls. People over the age of 60 have the highest incidence of fatal falls (WHO, 2021). The Centers for Disease Control and Prevention ([CDC], 2023) has noted that falls are costly and common among Americans aged 65 and older, with 36 million falls reported by older adults each year. Reasons for older adult patients falling during hospitalization include patient-specific fall risk factors, cognitive impairment, decline of motor function, medications, and comorbidities (Noh et al., 2021). Within the current population of people aged 55 or older, approximately 20% suffer from a mental health disorder; the most common diagnoses are anxiety, cognitive, and mood disorders (Corn et al., 2022).

Providing care for geropsychiatric patients can be challenging. Licensed and unlicensed healthcare staff who work with these patients sometimes experience burnout or conditioning to these challenges that may result in a less active response and thus a significant impact on patient safety (Ryu & Shim, 2021). Nurse burnout may also affect motivation for work or an attitude of indifference to patients, also possibly creating more patient safety risks (Ryu & Shim, 2021). Hakvoort et al. (2021) specifically identified poor staff attitudes as a hindrance to preventing falls. Falls are considered a nurse-sensitive incident because fall prevention is impacted by the quantity and quality of nursing care (Dykes et al., 2020). Staff education about this challenge should begin at time of hire and be ongoing to assess barriers or complacency to fall prevention methods. Falls can cause injuries that require longer recovery and extended hospital stays (Chidume, 2021).

Fall T.I.P.S. Toolkit
A research team for the Agency for Healthcare Research and Quality (AHRQ), led by Drs. Patricia Dykes and David Westfall Bates, developed the Fall T.I.P.S. toolkit to promote fall prevention and patient safety and is utilized in more than 100 hospitals based in the United States (U.S.) and other international settings (AHRQ, 2021). Fall T.I.P.S. uses a valid fall risk assessment scale as a base to provide fall prevention techniques and engage patients and families in a personalized fall prevention plan (Dykes et al., 2019). During initial implementation and testing of Fall T.I.P.S., fewer patient falls were noted in the intervention groups versus the control groups. The Fall T.I.P.S. toolkit includes a 3-item output to alert staff of fall risks and how to prevent falls. The three parts include a Fall T.I.P.S. poster, patient and family education that is tailored to specific needs, and a patient tailored plan of care.. All licensed and unlicensed staff have access to this information with the poster immediately visible as a personalized visual at the bedside for the care team to easily recognize and act quickly to prevent falls (Dykes et al., 2019).

The Fall T.I.P.S. toolkit was originally implemented at Brigham and Women’s Hospital in Boston, MA but has since been implemented throughout the United States and internationally. Recommendations for patient specific fall prevention methods to be used are based on the type of patient and known illnesses (Turner et al., 2022). Psychiatric patients require unique assessment due to unique risk factors (Wong et al., 2021). Older adult patients are at greater risk of falling in general because of advanced age and comorbidities (Wong et al., 2021). The addition of psychiatric illnesses for an older adult patient can promote further complications and concerns.

The Fall T.I.P.S. toolkit poster includes one section for staff to place a checkmark on risks that apply, such as: history of falls, medication side effects, walking aid requirements, intravenous pole or other equipment, unsteady gait, and whether the patient may forget or choose not to call for help. The other section of the poster has items for staff to circle based on the checkmarks of the first section; for example, walking aids to circle are crutches, cane, or walker; intravenous assistance when walking; toileting schedule with a bed pan, assist to bedside commode, or assist to bathroom; bed alarm use; and assistance out of bed requiring one or two people if patient is not on bed rest.

Brief Comparison of Fall Prevention Tools
Among a wide variety of fall prevention interventions, the Fall T.I.P.S. toolkit was chosen for this project as the most effective and user-friendly. Our evaluation considered the following factors . Along with lacking psychiatric-specific assessment factors, the Hendrich II Fall Risk Model (HIIFRM) and Sunnyview Test Scale poorly identify fall risk factors of inpatients (Menard et al., 2025). The Johns Hopkins Fall Risk Assessment Tool (JHFRAT), while widely used to prevent falls, is reportedly inconsistent in its statistical characteristics (Hong et al., 2024). A broadly popular fall risk tool is the Morse Fall Scale (MFS). It is commonly used in the hospital setting to identify patients at risk for falling (Jewell et al., 2020) but lacks psychiatric assessment factors. The Edmonson Psychiatric Falls Risk Assessment Tool (EPFRAT) is a psychiatric-specific tool that elevates nursing clinical judgment when recognizing high-risk patients (Mathew et al., 2020). With its ease of design and visibility for staff, the Fall T.I.P.S. toolkit was ultimately chosen to determine its effectiveness on fall prevention and self-efficacy of nursing staff within a geropsychiatric unit.

Healthcare Staff Self-Efficacy
Fall prevention education for staff is a priority to ensure safety for hospitalized patients (Shaw et al., 2021). Collaborative training about how to utilize the appropriate method for geropsychiatric patients is key to providing evidence-based fall prevention. Staff are usually the first to notice changes in patient cognition or physical condition which should then be communicated to other members of the healthcare team (Australian Nursing & Midwifery Federation, 2021). Patients may become unfamiliar with their locations, medications, or treatments provided in the hospital, causing them to become mentally confused, weak, and unsteady (AHRQ, 2021). Staff working together and understanding specific roles can aid in the overall quality of patient care (DiGerolamo & Chen-Lim, 2021).

Methodology

Design
The purpose of this pilot study was to determine the impact of the Fall T.I.P.S. toolkit on self-efficacy among licensed and unlicensed staff. A convenience sampling method was utilized to recruit participants. Institutional Review Board (IRB) was granted in addition to approval from the community hospital and geropsychiatric unit manager.

Setting and Sample
The setting for this project was a senior behavioral care unit (SBCU) in a rural hospital in Alabama. The hospital is a general acute care hospital licensed for 97 beds. The facility offers a full range of inpatient and outpatient services to a population of approximately 35,000. The unit provides geropsychiatric short term care to patients aged 55 and older. A mixed pool of providers work on the geropsychiatric unit, including a psychiatrist, nurse practitioner, social workers, registered nurses, licensed practical nurses, and patient care technicians. The registered nurses, licensed practical nurses, and patient care technicians were represented in the sample size. There are approximately 22 admissions monthly.

Intervention
As a nurse-led intervention, the Fall T.I.P.S. toolkit was implemented on the geropsychiatric inpatient unit to aid in fall prevention. Invitation to participate in the study was sent via the hospital employee messaging portal, and informed consent was obtained. Prior to toolkit training, the Self-Efficacy for Fall Prevention for Nurses (SEPF-N) and Self-Efficacy for Fall Prevention for Nursing Assistants (SEPF-A) (ADD REFERENCE) were administered electronically to participants. All geropsychiatric unit staff were required to complete T.I.P.S. training via an online training module, and then the Fall T.I.P.S. toolkit was implemented over a six-week period.

(AUTHORS: I would like to reference these tools. I capitalize the name of them here is the name of the tool. First, please confirm that that is correct as written above. Second, please look for the primary reference for publication of the tools for use – in other words, the first article that was published introducing them to the literature, and reference that article here, and on the reference list. One more thing – was this tool for you to use or did you have to pay? Did you request permission to use it? A sentence or two clarifying that would be helpful. Let me know if you have any questions. Thanks, Jackie)

Laminated Fall T.I.P.S. toolkit posters were placed on the outside of each patient room door and were used upon admission for all patients. These were updated as needed for any changes of care during the patient’s hospital stay. Staff marked pertinent patient fall risk indicators including gait, medication side effects, previous falls, use of cane or walker, and bathroom assistance. The posters were visible to all staff on the outside of the door to aid in providing care even if unfamiliar with the patient. Approximately six weeks post implementation of the Fall T.I.P.S. toolkit, the SEPF-N and SEPF-A were readministered to participants.

Measurement Tool
The SEPF-N and SEPF-A scales were created to measure bedside staff provider self-efficacy and beliefs about patient fall prevention. The 11-item SEPF-N and 8-item SEPF-A asked staff questions regarding their self-efficacy in preventing patient falls (Leverenz & Lape, 2021). The SEPF-N and SEPF-A questions measure responses on a Likert-type scale ranging from 1 to 6, increasing in confidence with each numerical increase. Reliability and validity have been demonstrated by the scales relative to individual items scale totals (Leverenz & Lape, 2021). During development and testing, Dykes et al. (2019) confirmed reliability with a Cronbach alpha of 0.89 for the SEPF-N and a Cronbach alpha of 0.74 for the SEPF-A. Content validity for the SEPF-N and SEPF-A are p = 0.09 and p = 0.11 respectively.

Results

The pilot study sample consisted of all female participants with varying years of experience in healthcare and included day shift and night shift providers. Sample demographics including age, gender, race, years of experience, years of experience at site, and education level are found in Table 1. A total of 54 responses were collected in the pre-survey data, surpassing the original recruitment goal of 40 participants. Participants were asked to input a 4-digit number that only they knew (e.g., last four digits of phone number). This number was used to link the pre-survey to the post-survey. A total of 23 responses were collected in the post-survey data, despite numerous reminders and efforts to increase this number. Comparing pre- and post-survey data, only 11 participants used the same four-digit identification number. Therefore, only a small portion of the sample could be used to measure pre- versus post-survey changes. This greatly impacted the overall sample size and statistical significance.

Table 1. Characteristics of the Study Sample (n = 11)

Our findings revealed a decrease in the total number of falls (from 7 to 4) during the implementation period in comparison to the number of falls during the same time period in the previous year. The mean (M), standard deviation (SD) and range for each SEPF-N question as compared between the pre- and post-survey are found in Table 2. The SEPF-N tested the self-efficacy of nurses in preventing patient falls, with increased M indicating an increase in self-efficacy and decreased M indicating decreased self-efficacy. Five of the 11 survey questions indicated increased M between the pre- and the post-surveys. These questions were: 1, 2, 4, 5, and 6. Five of the 11 survey questions indicated decreased M between the pre-and the post- surveys. These questions were: 3, 8, 9, 10, and 11. Question 7 related to giving nursing assistants face-to-face report about their patients’ fall risk and indicated no change in the M (5.71) between the pre- and post-intervention survey.

Table 2. Pre/Post Comparison of Mean, Standard Deviation and Range of SEPF-N (n = 7)

The M, SD, and range for each SEPF-A survey question as compared between the pre- and post-survey are found in Table 3. The SEPF-A tested the self-efficacy of assistants in preventing patient falls, with increased M indicating an increase in self-efficacy and decreased M indicating decreased self-efficacy. The survey question responses mirror those of the SEPF-N. Five of the eight survey questions indicated increased M between the pre-and the post-surveys. These questions were: 3, 4, 5, 7, and 8. Question 2 indicated a decreased M between the pre-and the post-intervention surveys. Two survey questions, 1 and 8, indicated no change in the M between the pre- and the post-intervention surveys.

Table 3. Pre/Post Comparison of Mean, Standard Deviation and Range of SEPF-A (n = 4)

We calculated Cronbach α to determine the internal reliability of the SEPF-N and SEPF-A survey tools. The resulting value for the SEPF-N was α = 0.856; the value for the SEPF-A was α = 0.832. These results meet the acceptable level for the test and confirmed the tool’s internal reliability.

A Wilcoxon signed rank test was performed to determine if the Fall T.I.P.S. toolkit led to increased self-efficacy in staff ability to prevent patient falls. Self-efficacy improvement is noted by a positive behavior change with goal oriented and motivational characteristics (Leverenz & Lape, 2021). Wilcoxon test results for SEPF-N and SEPF-A are shown in Tables 4 and 5, results revealed no statistical significance among participants.

Table 4. SEPF-N Survey Wilcoxon Rank Tests

Table 5. SEPF-A Survey Wilcoxon Rank Tests

Discussion

In our pilot study, the Fall T.I.P.S. toolkit demonstrated an effective method to prevent falls and improve self-efficacy among staff on the geropsychiatric inpatient unit. At high risk due to cognitive function, psychotropic medications, and physicality issues, these geropsychiatric patients benefited from the healthcare staff devising personalized fall prevention plans. Both licensed and unlicensed staff showed an increase in self-efficacy based on their average means, however, the unlicensed staff participants showed a greater increase. This impact could be due to licensed staff having exposure to similar fall prevention education in nursing program and continuing education courses versus unlicensed staff receiving this fall prevention education with little or no previous exposure.

The Fall T.I.P.S. toolkit has been implemented in various settings to determine its effectiveness. One quality improvement project determined the effectiveness of the Fall T.I.P.S. toolkit among fall prevention in older adult nursing home residents in a subacute care unit in Canada, also noting a decrease in falls (Tzeng et al., 2021). Another study performed by Padilla et al. (2020) in affiliation with Rutgers University, the Fall T.I.P.S. toolkit was implemented on a psychiatric inpatient unit and showed a 14% decrease in the number of falls. The decreased number of falls in this study supports previously published evidence that the Fall T.I.P.S. toolkit is an effective program to reduce falls (Dykes et al., 2020).

The Fall T.I.P.S. toolkit may also demonstrate usefulness in other care settings. Due to its patient tailored nature, the tool can be used for patients who do not require geropsychiatric care. In a nonrandomized controlled trial performed by Dykes et al. (2020), patient engagement was noted to be a key factor in reducing the number of falls in younger patients. Although older adult patients are at a greater risk for falls, the trial did show fewer falls among younger patients (Dykes et al., 2020). Younger patients believe they are not at risk for falls in hospitals, specifically those who are independent in their everyday lives, but nonetheless are less likely to experience falls if they are more involved with their three-step fall prevention plan (Dykes et al., 2020).

Limitations and Recommendations

A larger sample size would be beneficial to gather data on healthcare staff self-efficacy. The sample size for the study was much smaller than anticipated due to the low number of matched four digit numbers on the pre-and post-surveys. This small sample size limited generalizability and likely contributed to the lack of statistical significance. The inability of the healthcare staff to remember their previous four-digit pre-survey code and utilize the same code in post-survey resulted in the smaller sample. We recommend a different identification method to match surveys while assuring anonymity. However, licensed and unlicensed staff self-efficacy and knowledge of fall prevention was exhibited in the pre- and post-intervention surveys.

Additionally, it would have been beneficial to extend the six-week time frame to determine the effectiveness of fall prevention. Although the number of falls was reduced compared to the same time frame from the previous year, several variables were at play. Patient demographics and diagnoses were not collected, making it difficult to determine if the personalized fall prevention plans were effective for a broad range of patients. Future research should include more patient details as fall prevention is not “one size fits all.”

Conclusion

The Fall T.I.P.S. toolkit is an effective tool to prevent patient falls and improve self-efficacy of licensed and unlicensed and licensed healthcare staff in a geropsychiatric inpatient unit. Overall, our patients benefited from the project, likely due to the effectiveness of a personalized fall risk/prevention plan. The hospital also benefited from this project because reduced falls support reimbursement and quality performance rates.

Declaration of Interest Statement

There are no financial or personal interests or beliefs that affect the project’s objectivity. No actual or potential competing interests exist.

(AUTHORS: We are now including author ORCID IDs, if available. This is not mandatory. If you have one, please provide it to us and it will be included. If you do not, we will remove that heading from under your bio. For articles with multiple authors, please provide this information to the corresponding author who can submit it with the galley proof edits.)

Authors

Morgan R. Sewell, DNP, RN
Email: mrsewell@troy.edu

Morgan Sewell is a Lecturer at Troy University School of Nursing in Montgomery, AL. She was licensed as an LPN and earned an ASN from Lurleen B. Wallace Community College, and BSN and DNP degrees from Troy University. She has been employed in academia for one year and has worked for over 12 years in a regional acute care facility.

Jeffery W. Forehand, PhD, DNP, RN, MEDSURG-BC, NI-BC, CNE
Email: jforehand@troy.edu

Jeffery W. Forehand is the Director, Troy University School of Nursing in Montgomery, AL. Dr. Forehand received BSN and MSN degrees from Troy University and DNP and PhD degrees from the University of Alabama. He has been employed in academia for over 13 years and continues to practice bedside nursing on a neuro/ortho medical-surgical floor.

Brittney O. Armstrong, DNP, RN, CNE
Email: boarmstrong@troy.edu

Brittney Armstrong is an Associate Professor at Troy University School of Nursing in Montgomery, AL. She received BSN, MSN, and DNP degrees from Troy University. She is a Certified Nurse Educator. She has been employed in academia for over 18 years and continues to work clinically in a regional acute care facility.