Adult Inpatients’ Perceptions of Their Fall Risk: A Scoping Review

Patient falls in hospitals continue to be a global concern due to the poor health outcomes and costs that can occur. A large number of falls in hospitals are unwitnessed and mostly occur due to patient behaviours and not seeking assistance. Understanding these patient behaviours may help to direct fall prevention strategies, with evidence suggesting the need to integrate patients’ perspectives into fall management. The aim of this scoping review was to explore the extent of the literature about patients’ perceptions and experiences of their fall risk in hospital and/or of falling in hospital. This review was conducted using a five-stage methodological framework recommended by Arksey and O’Malley. A total of nine databases were searched using key search terms such as “fall*”, “perception” and “hospital.” International peer-reviewed and grey literature were searched between the years 2011 and 2021. A total of 41 articles, ranging in study design, met the inclusion criteria. After reporting on the article demographics and fall perception constructs and measures, the qualitative and quantitative findings were organised into five domains: Fall Risk Perception Measures, Patients’ Perceptions of Fall Risk, Patients’ Perceptions of Falling in Hospital, Patients’ Fear of Falling and Barriers to Fall Prevention in Hospital. Approximately two-thirds of study participants did not accurately identify their fall risk compared to that defined by a health professional. This demonstrates the importance of partnering with patients and obtaining their insights on their perceived fall risk, as this may help to inform fall management and care. This review identified further areas for research that may help to inform fall prevention in a hospital setting, including the need for further research into fall risk perception measures.


Introduction
Patient safety in healthcare settings continues to be recognised as a global health priority. Current evidence shows that up to 83% of harm to patients is avoidable, producing additional costs of up to 15% of hospital expenditure in high-income countries [1]. Falls in hospitals constitute one of the greatest sources of patient harm on a global scale, with up to 80% of falls occurring in low-to middle-income countries [1]. Approximately 700,000 to 1 million patient falls occur in hospitals in the United States of America alone, contributing to 250,000 injuries and up to 11,000 deaths [2]. Patient falls continue to be a high priority for healthcare organisations due to the detrimental physical, psychological, social and financial consequences that can occur.

Background
Despite decades of research, there is a lack of robust evidence relating to the efficacy of fall interventions in hospitals, including exercise regimes, medication reviews, bed alarms, patient education or assistive technology [3]. A worldwide taskforce has been established to update fall prevention and clinical management guidelines [4] with the

Screening and Eligibility
The inclusion and exclusion criteria were developed by all four authors (ED, SC, JD and KM) to achieve general consensus about the eligibility criteria. The focus of the included studies was on perceptions or attitudes about falling or about their fall risk in hospital. The authors included a variety of constructs that conveyed perception, as shown in Table 1. Articles were included if participants were adults aged greater than 17 years and were hospital inpatients, including emergency departments. The exclusion criteria were studies that occurred in community or residential facilities/aged care and hospital outpatient clinics, including short-stay procedures. Studies were excluded if the focus of the paper was on the development of fall risk perception measures. The review considered all types of published papers that met the inclusion criteria.
After the search results were uploaded to Covidence [15] and duplications were removed, two authors (ED and SC) completed an independent title and abstract screen. In the event of uncertainty, a third author (KM) moderated the process until consensus was reached. The approved screened records were then obtained in full text by author ED and further evaluated by the research team to determine their relevance to the aims of the scoping review. All four authors approved the final list of articles for this scoping review, and a final check of selected papers was included to ensure that papers had not been retracted [13]. Figure 1 details the flow of the literature search process and study selection for this review. Table 1. Articles were included if participants were adults aged greater than 17 years and were hospital inpatients, including emergency departments. The exclusion criteria were studies that occurred in community or residential facilities/aged care and hospital outpatient clinics, including short-stay procedures. Studies were excluded if the focus of the paper was on the development of fall risk perception measures. The review considered all types of published papers that met the inclusion criteria.
After the search results were uploaded to Covidence [15] and duplications were removed, two authors (ED and SC) completed an independent title and abstract screen. In the event of uncertainty, a third author (KM) moderated the process until consensus was reached. The approved screened records were then obtained in full text by author ED and further evaluated by the research team to determine their relevance to the aims of the scoping review. All four authors approved the final list of articles for this scoping review, and a final check of selected papers was included to ensure that papers had not been retracted [13]. Figure 1 details the flow of the literature search process and study selection for this review.

Quality Appraisal
Quality appraisal is not always a required component of scoping reviews, given the potential to include grey literature [12]; however, this element is recommended by Cooper, Cant [13] to improve rigor. The quality appraisal process was completed by two authors independently, with a third author to moderate if a general consensus was not reached. An array of appraisal tools was utilised, depending on the individual study designs. Qualitative studies were appraised using the Critical Appraisal Skills Program (CASP) Qualitative Studies checklist [16], in which studies were scored on 10 items. Quantitative studies were evaluated on 12 items using the CASP Cohort Study Checklist [17] and the CASP Randomised Controlled Trial Checklist [18]. It is not always necessary to provide an overall score using CASP tools [16]; however, the authors opted to include overall scores given the summative scoring system of this quality appraisal process. The quality of quasi-experimental studies was appraised using the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Quasi-Experimental Studies [19]. Mixed methods studies were evaluated using the Mixed Methods Appraisal Tool (MMAT) [20]. Literature reviews were appraised using the six-item Scale for the Assessment of Narrative Review Articles (SANRA) [21]. The quality of case reports was assessed using the JBI Checklist for Case Reports [22], which consists of eight items. The doctoral dissertations and editorial column included in this scoping review were not subject to quality appraisal. The overall scores were included in a data summary table to rate the quality of evidence against validated quality appraisal tools.

Data Charting
A data charting form was developed based on the recommendations of Arksey and O'Malley [10] to map the key concepts and themes identified from the scoping review. After collaboration between all authors, it was decided that the following data were to be extracted verbatim: author, year and country, study aim, study design, study population, fall risk perception outcome measures and main findings. The data extraction was completed by the lead author, and all authors reviewed the extracted data to verify the final dataset. One corresponding author of a study was contacted via email on 12 August 2021 for additional information; however, they did not respond to our email. Consequently, we were unable to source further information about the fall risk perception measures reported in their study. In accordance with Cooper, Cant [13], a numerical analysis of the extent and nature of included studies was also reported.

Data Synthesis
To provide a narrative account of the results, the authors familiarised themselves with the data and revisited the research objectives. The main qualitative and quantitative findings from each article were grouped into five domains: Fall Risk Perception Measures, Patients' Perceptions of Fall Risk, Patients' Perceptions of Falling in Hospital, Patients' Fear of Falling and Barriers to Fall Prevention in Hospital. These domains were inductively developed from the findings of the review. The lead author collated the information into the five domains, providing a comparison between the relevant studies. All authors reviewed the domains and findings prior to summarising and reporting the results. Minor changes were made to the review protocol to incorporate the mapping of fall risk perception measures and identified barriers to fall prevention in hospitals. Results from a scoping review may be further refined towards the end of the review, as authors will have greater insight into the nature of the included studies [12].

Article Characteristics
From the initial database search, a total of 8527 citations were identified, as shown in the PRISMA flowchart (Figure 1). Following a systematic process, 41 articles published between 2011 and 2021 were identified and included in this review (see Table 2). The included articles were predominantly from the USA (n = 18), with some studies conducted in Australia (n = 6) and the UK (n = 4). The remainder of the studies were from Germany (n = 2), Iran (n = 2), Singapore (n = 2), Turkey (n = 2) and 1 each from Denmark, China, Pakistan, Taiwan and Vietnam. A data summary table of the 41 articles can be found in Appendix B.

Description of Fall Risk Perception Measures
There were variations in the constructs used to describe patients' fall perceptions, with a total of 25 validated tools utilised to quantify fall perception. The single-item question "are you afraid of falling?" was the most frequently used fall perception measure [23,26,34,36,[44][45][46], followed by the 16-item Fall Efficacy Scale-International (FES-I) [23,35,44,[47][48][49] and the 7-item shortened version of the Fall Efficacy Scale-International [28,36,37,49,50]. The Falls Efficacy Scale (FES) also featured in five studies [24,48,49,51,52], with one study utilising the shortened FES [31]. Physiological fall risk tools were incorporated into some studies (n = 8) to compare patients' perceptions with their actual fall risk. The Self-Awareness of Falls Risk Measure (SAFRM) was noted to be the only validated measurement tool that incorporated both the patients' and clinicians' perceptions of fall risk using the same measure [29,30].
Many studies utilised fall perception measures such as the FES and FES-I to measure fear of falling; however, it has been established that fear of falling and fall self-efficacy are different constructs [36]. In one study, participants' self-efficacy improved after a fall question-and-answer education intervention [38], whereas there was a lack of significant findings on fall self-efficacy with the implementation of a multimedia fall prevention program [51]. Further, there were reports of an association between high medication use and lower fall self-efficacy and engagement in fall prevention strategies [51]. A low fall self-efficacy rating was also related to poor physical performance [36].

Description of Patients' Perceptions of Fall Risk
A prominent emergent theme was the disparity between patients' perceived fall risk and their clinical risk of falling. Patients did not consider themselves to be at risk of falling [32,39,40,46,[53][54][55][56][57], and in three studies, approximately one-third of participants accurately identified their fall risk [28,29,44]. These statistics contrast with Radecki, Reynolds [58], as more than half of participants accepted that they were at risk of falling. Similarly, the findings of Greenberg, Moore [31] demonstrate alignment between participants' perceived and actual risk. However, the tool used was not a validated fall risk assessment (Vulnerable Elders Survey). The importance of conducting comprehensive assessments was highlighted in Byrd [59]. In this study, clinicians were unaware of the presence of anosognosia in stroke participants, suggesting that these participants may have had inadequate fall prevention management. Despite fall prevention education, some patients overestimated their own ability in a hospital setting and were unaware that their fall risk could change with their medical condition [57]. A falls expert who recounted their own personal patient experience affirmed, "Despite all the cues that nursing staff were giving me, I could not grasp that I was at high falls risk" [60]. Evaluating both patients' perceived and actual fall risk is essential to inform fall prevention education and strategies [44,55,61].

Description of Patients' Perceptions of Falling in Hospital
The perception of the loss of independence and autonomy was highlighted in Gettens, Fulbrook [42] and Radecki, Reynolds [58], in which participants' described their desire to be perceived as physically competent by others. Feelings of disappointment and disempowerment were expressed over their loss of independence after a hospital fall; however, this produced a behavioural change in which patients were more receptive to assistance [42]. These changes were also noticed in Turner, Jones [27], where participants reported increased reliance on nursing staff and a subtle shift in the locus of control after their falls. Self-blame with admissions of guilt over risk-taking behaviour was identified in Lim, Ang [57], with one person disclosing, "It was because I refused to listen to other people's advice. I wanted to take the risk to try (walking) by myself." An older adult's motivation for maintaining independence and assuming risk-taking behaviours can be attributed to a desire to go home [43].
An emerging theme was patients' lack of awareness over the causes of their hospital falls. Differing opinions were observed between patients and nurses in the work by Hoke and Zekany [54], in which patients attributed their falls to environmental factors, whereas nursing staff attributed their falls to "not calling for assistance." Patients were more likely to blame extrinsic factors for their falls and did not understand the multifactorial basis behind falls [32]. Similarly, falls were perceived to be mechanical in nature and were referred to as a "loss of balance", rather than to medication use or pre-existing conditions [27]. Patients were more receptive to interventions from health professionals following their hospital falls [32,42].

Description of Patients' Fear of Falling
There were varied emotions and beliefs around the possibility of falling in hospital. Emotions ranged from apathy or no concern to extremely worried [32,62]. Falls were not considered to be a medical or life-threatening issue for some patients [57]; thus, some participants failed to see the consequences of a fall. The term "fear of falling" was frequently used in studies to determine patients' fall perceptions and is associated with a range of adverse health and psychosocial outcomes [63]. A fear of falling was associated with higher levels of anxiety and reduced social support [26], reduced self-related quality of life scores and higher risk of falling [24] and higher dependency in activities of daily living (ADLs) [24]. There was also a higher association between fear of falling in women and those without a spouse [26,47,52]. Fear of falling increased after a hospital fall, with a reduction in confidence and reduced self-efficacy [27]. Self-perceived factors for increased fear of falling included balance difficulties, dyspnoea, muscle weakness and a history of falling [23,63].

Description of Barriers to Fall Prevention in Hospital
Patients' thoughts and feelings about their own recovery were identified as the main barrier to engaging with fall prevention strategies [25]. Participants were more likely to engage in fall prevention if they viewed their fall risk as temporary rather than permanent [61]. In Twibell, Siela [56], 10% of participants acknowledged that they had no intention of using the call bell to request assistance when mobilising. Self-identity was important for participants, especially if they considered themselves to be strong and independent. Some participants had difficulty accepting fall prevention strategies that threatened their perceived self-identity, such as the use of a walking frame to ambulate [61].
Participants reported high confidence in the ability of the nursing staff to keep them safe. In Sonnad, Mascioli [46], 40% of patients did not consider themselves to be a fall risk because of high-quality nursing. Despite fall education delivered by nurses, the reduced use of the hospital call bell for requesting assistance was noted in some studies [50,54,62]. A common reason identified for this was that participants considered the nurses to be busy and did not want to impose on them [25,43,57]. Negative experiences or attitudes towards "unfriendly" nursing staff were also recognised as a factor in noncompliance with call bell use [43,57,62]. Some participants identified that delayed assistance from nurses instigated their risk-taking behaviour, leading to a risk of falling [25,43,58,62]. Valuing one's dignity was considered a priority over potential falls. Avoiding incontinence and subsequent feelings of embarrassment took precedence over the risk of falling, as expressed by some participants [25,43,57,58,62].

Discussion
This scoping review explored the literature relating to patients' perceptions of their fall risk in a hospital setting and their experiences of falling. To the best of our knowledge, this review is the first of its kind to investigate the scope of evidence around fall risk perceptions. Of the articles, 83% originated from high-income countries, as defined by the World Bank Group [64], with only 17% of studies conducted in low-to middle-income countries that met the inclusion criteria. As the majority of fall-related deaths occur in low-and middleincome countries [65], increased fall prevention efforts in low-and middle-income countries are essential.
Guidelines recommend that people over the age of 65 years be considered at risk of falling in hospital [66]. Interestingly, the studies that explored patients' experiences of falling in hospital encompassed a wide age range, which suggests that all adult hospital inpatients could be considered at risk of falling. Fall risk assessment tools are traditionally completed by clinical staff to identify risk factors, thus producing an overall fall risk score in which individual interventions are implemented. This suggests that it is important to consider all hospital inpatients as a possible fall risk and to tailor fall prevention strategies accordingly. Fall risk assessment tools are traditionally completed by clinical staff to identify risk factors, thus producing an overall fall risk score in which individual interventions are implemented. Studies that divested from fall risk screening tools in favour of clinical reasoning reported "non-inferior" fall outcomes and potential improvements in fall rates [67,68]. Similarly, updated UK guidelines state: "Do not use fall risk prediction tools to predict inpatients' risk of falling in hospital" [66]. The use of fall risk assessment tools can lead to complacency or a "checklist exercise", resulting in inadequate fall prevention management. This highlights the importance of performing comprehensive multifactorial assessments and tailoring fall prevention strategies to the patient, rather than adopting a fixed approach.
A major finding from this scoping review, in line with the first research objective, is the disparity between patients' fall perceptions and their physiological fall risk in hospital. This also confirms the qualitative findings of Heng, Slade [6] and of Dolan, Slebodnik [69], in which participants were not aware of their risk of falling despite having multiple risk factors for falling. Although this mismatch of fall risk is established, only one instrument (Self-Awareness of Falls Risk Measure) directly measures the fall risk disparity from the validated fall perception measures. The Self-Awareness of Falls Risk Measure is the first scale of its kind to measure self-awareness of fall risk in hospital and to quantify the disparities between clinicians' and patients' perceptions [70]. Under-or overestimations of fall risk are different constructs, meaning that the causes of these perceptions are varied, and management plans are dependent on their classification [70]. For example, a person who overestimates their fall risk will likely benefit from interventions geared towards their "fear of falling", as opposed to someone who underestimates their fall risk and may otherwise engage in risk-taking behaviour. This approach to fall risk assessment aligns with current guidelines that recommend assessing the older person's perceived functional ability and fear of falling [66]. The Self-Awareness of Falls Risk Measure may be of valuable use in a clinical setting, especially because it is also validated for those with mild to moderate cognitive impairment [70].
People with cognitive impairment are often excluded from gerontological research [71] yet have a higher risk of falling compared to those who are cognitively intact [72]. The term anosognosia is frequently associated with neurological impairments, in which patients are not aware of their physical deficits [73]. Anosognosia may be an important factor in explaining the discrepancy between actual and perceived fall risk in people with dementia, leading to risk-taking behaviour [63]. In one study, clinicians were unaware of the presence of anosognosia in 100% of the cases, potentially leading to inadequate fall management [59]. These findings demonstrate the importance of incorporating fall risk perception measures into assessments, especially for people with cognitive impairment [28].
Another prominent theme from the literature is the importance of patient dignity and perceptions of autonomy, which may influence compliance with a fall management plan. Feelings of disempowerment, loss of independence [42,58] and threats to perceived self-identity [61] demonstrate the vulnerability that older adults can experience in hospital. Basic human needs and personal care were fundamental to participants and were regarded as higher priorities than the possibility of falling [25,43,57,58,62]. Person-centred care involves seeking out and understanding what is important to the patient and adopting a collaborative approach based on elements such as respect, emotional support and care co-ordination [74]. Shared decision-making should feature in all healthcare settings as a pathway for health professionals and patients to work together to make decisions about care [75]. This verifies the importance of seeking patients' perceptions and viewing subjective data as a valuable source of information to inform care and management [27].
Communication breakdown was identified as the overarching main barrier to patient engagement with fall prevention strategies. Whether it be decreased call bell use [43,50,54,56,62], prior negative experiences with nursing staff [43,57,62] or delayed assistance [25,43,58,62], communication failure could be attributed to various instances of noncompliance by patients. This also extended to interprofessional miscommunication between disciplines and on nursing clinical handovers [43]. To address communication issues, standardised communication tools have been devised, such as the SBAR tool (situation, background, assessment and recommendation) for interprofessional communication [76] or the TOP 5 intervention, which is five personalised important tips to aid communication between health professionals and people with dementia [77]. Evidence suggests that improving communication, partnering with patients and/or their families and seeking feedback lead to greater patient satisfaction and improved health and safety outcomes [74].
This review also determined that there were inconsistencies with patients' perceptions of their causes of falling in hospital. Older adults were more likely to blame their falls in hospitals on external factors [27,32,54] and were unaware of contributing intrinsic factors, such as medication use or changes in medical conditions. These findings are comparable to Heng, Slade [6], who additionally identified that participants may have feelings of indifference towards fall education, as they did not consider it to be relevant to their needs.
Patient fall education forms a considerable part of multifactorial fall interventions, in which guidelines recommend that individuals at risk of falling should be offered education orally and in writing [66]. Interestingly, a Cochrane review reported that the provision of educational materials may not affect the risk of falling in hospital, and there was very low-quality evidence of the effects of educational sessions on fall rates [3]. A meta-analysis has since found that education has a positive effect on hospital falls rate and risks, however further research is needed to determine optimal design and delivery [78]. The design and delivery of fall education should be individually tailored to the person, specific to their fall risk, and incorporate an active learning design for improved engagement [79].
"Fear of falling" or post-fall syndrome [80] describes people who have an anxiety of falling, which impacts their activity levels and independence, but may not have necessarily experienced a fall [81,82]. It is important to assess a person's fear of falling along with their fall history to determine if they have a diagnosis of fear of falling syndrome [33]. Interestingly, Eckert, Kampe [36] found that fear of falling and fall self-efficacy are two separate constructs, yet some studies continue to incorporate self-efficacy measures to assess fear of falling. The Falls Efficacy Scale was developed based on the following definition: "low perceived self-efficacy at avoiding falls during essential, nonhazardous activities of daily living" [83]. Fall efficacy and confidence measures may not convey a true indication of fear of falling, as older adults may feel confident in activity engagement but may still harbour fears of potential falls [84]. This review exposes a gap and confirms that many studies continue to utilise the Falls Efficacy Scale measure and its variants to measure fear of falling in older adults. Given that these outcomes may not provide a true depiction of this phenomenon, further research should investigate these fall perception measures and their use within the clinical setting.

Implications for Future Research
In line with the second research objective, future research should focus on conducting a systematic review of existing fall risk perception measures to determine their suitability for use in a hospital setting. A comprehensive summary of their measurement properties and feasibility could be further investigated. In addition, researchers should consider the inclusion of people with cognitive impairment for future studies on fall perception, as their contribution should be valued.

Limitations
The limitations of this review include the use of English-language papers only. Scoping reviews are not intended to be a definitive synthesis of the literature; however, they are useful for disseminating research findings on a topic and identifying gaps in the literature [13,85]. Irrespective of these limitations, this review provides a valuable contribution to fall research by scoping the literature relating to patient perceptions of their fall risk in hospital.

Conclusions
This scoping review provides a detailed review of the research findings pertaining to patient perceptions of their fall risk in hospital. Approximately two-thirds of study participants did not accurately identify their fall risk compared to that defined by a health professional. This demonstrates the importance of partnering with patients to gain insight into their past experiences that may contribute to risk-taking behaviours. Regular collaboration with patients and seeking their feedback are also essential to communicating for safety. Opportunities for further research were identified in this review, which may provide meaningful contributions to improve fall knowledge on a global scale. Funding: This research received no external funding. The first author is the recipient of a full PhD scholarship from Federation University Australia and Latrobe Regional Hospital.            • Patients with some concern over future falls were able to name some modifiable risk factors.

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Patients with little to no concern of future falls minimised any risk factors or already partook in their own perceived risk-reducing activities.