Nurses’ Experiences in Implementing Fall Risk Prevention Procedures in Inpatient Units

Abstract

Patient falls remain among the most frequent preventable adverse events in hospitals, posing challenges to patient safety in inpatient care. Preliminary observations at RSUD Bendan Pekalongan revealed inconsistent initial assessments, incomplete patient and family education, and facility limitations that weakened fall prevention practices. This descriptive qualitative study explored nurses’ experiences in implementing fall risk prevention procedures in inpatient units. Five purposively selected participants, including nursing management, patient safety committee members, head nurses, and staff nurses, provided data through in depth interviews, observations, and document reviews. Thematic analysis identified two main themes: institutional guidance for fall risk identification and practical implementation of prevention measures. Nurses reported using patient identification protocols, the Morse Fall Scale, risk labels, side rails, environmental checks, and patient family education. However, implementation was inconsistent due to workload pressures, uneven knowledge and training, limited patient family engagement, and damaged facilities. Although structural procedures exist, process fidelity remains suboptimal.