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CE Article: Coaching project helps facilities prepare for patient falls*

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After reading this article, you will be able to:

  1. Identify the purpose of linkers and coaches in Donaldson's fall reduction project
  2. Discuss the importance of fall assessment and re-assessment tools

Patient falls have been a problem in hospitals for quite some time.

Nancy Donaldson, RN, DNSc, FAAN, clinical professor and director of the Center for Research and Innovation in Patient Care at University of California San Francisco School of Nursing, took the effect of, and attention paid to, patient falls into account when she began a project to reduce the incidence of patient falls and the severity of fall-related injuries.

Donaldson was able to begin her project with the help of the Collaborative Alliance for Nursing Outcomes Partners for Quality (CALNOC), formerly known as the California Nursing Outcomes Coalition, and information gathered from 77 medical-surgical units from the 33 CALNOC hospitals to serve as project sites. To learn more on CALNOC and its patient safety initiatives, click here.

Coaches and linkers collaborate

The project, which began in 2002 and lasted through the fourth quarter of 2006, used a telephone-based coaching tactic to collaborate with “linkers,” or fall prevention champions, located throughout the CALNOC system.

The idea of a linker was crafted by Donaldson using Havelock’s Linkage Model, which emphasizes the transfer of knowledge from knowledge generators to users. In this case, it was the coaches’ knowledge being shared with the linkers, who in turn shared their information with a CALNOC hospital.

“In the field of education, coaching is effective, not only for facilitating changes in practice, but also for building individual and organizational capacity for continuous improvement,” says Donaldson.

The linker was the facilitator between the CALNOC hospital and the coach. Every three to six weeks, the coach talked with the linker on the phone for 30–60 minutes.

The coaching team was made up of six RNs with specialized knowledge and skills related to research utilization, evidence-based practice, nursing services administration, and fall prevention strategies.

“We used the telephone because it was too expensive to hold monthly visits,” says Donaldson. “We did try to regionalize the calls, and most of our coaches made at least one site visit.”

From there, participating hospitals were asked to fill out a self-assessment tool to take inventory of policies and procedures related to fall risk assessment, prevention, and performance. Once staff members at the CALNOC hospitals filled out this self-assessment tool, coaches were assigned to linkers in each facility.

The coaches’ main purpose was to help linkers develop and implement improvements in fall-related organizational policies, and the coaches were encouraged to:

  • Monitor, listen, assess progress, and elicit feedback
  • Provide information and support
  • Identify action, help with planning, and clarify next steps
  • Provide referrals
  • Identify resources in the form of individuals, information, and energy

Also, each coach’s work was customized to a specific hospital culture and focused on targeted areas.

The linkers were encouraged to:

  • Develop an understanding of the organization’s fall patterns
  • Report monthly on fall incidents
  • Enter fall-related data in an event-reporting system

Mixed results

After the linkers and coaches collaborated for two years, CALNOC distributed another self-assessment to determine whether there were improvements in the rate of patient falls from when the project began.

Although the data showed little change had been made in preventing patient falls, there was an increase in how often hospitals reported on such events.

“Hospital pre- and postintervention self-assessments suggested minor and major changes,” says Donaldson.

Prior to the initiative, 53% of CALNOC hospitals did not evaluate fall prevention equipment, but after the initiative, the percentage climbed to 89%.

Also, hospitals that reported fall rates monthly or more often increased from 3% prior to the initiative to 39% after, or quarterly from 18% to 57%.

Overall, hospital responses to a fall incident became more systematic, incorporating more elements that would help improve fall prevention in the future.

In addition to improving these percentages on reporting and evaluating fall preventions, the CALNOC hospitals also took away some valuable practices.

The hospitals learned they must build a sufficient time frame for assessing performances, along with a leadership commitment.

The best-performing sites had strong commitment to falls reduction at the top levels along with a focus on the initiative for a minimum of two years. Also, many sites discovered it was better to customize fall prevention strategies to individual patient needs and thoroughly investigate each fall. Click here to read basic information on patient falls and why they occur.

Continuing to focus on falls

Despite the lack of hard data collected by CALNOC, Donaldson believes the project was a great success.

“We really feel the process was well received,” says Donaldson, who has stayed in touch with the CALNOC hospital members who participated in the study.

As a follow-up to the patient falls initiative, CALNOC is using data from 2006 to examine the difference between the best performers and the worst performers in the project.

Donaldson wants to see whether any parallels can be drawn between factors common among the best and worst performers.

“We look at the data and see who was the best for falls, and look a year later, half the best are no longer the best and half that were the worst are no longer the worst. There is a lot of shifting going on, which is interesting,” says Donaldson. Learn how other facilities are reducing the risks of patient falls by clicking here.

Source: Patient Safety Monitor, September 2009, HCPro, Inc.


1. Tideiksaar, Rein. (2009.) "Fall Prevention in Institutions." Available from

2. CalNOC. (2009). "Collaborative Alliance for Nursing Outcomes." Available from

3. UPMC Minute. (2009)."Reducing the Risks of Patient Falls." Available from

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