Running Head: WHEN YOUR BRAIN BECOMES A FALL RISK

When Your Brain Becomes a Fall Risk

PJ DiBenedetto
James Madison University
December 4th, 2015

WHEN YOUR BRAIN BECOMES A FALL RISK

Introduction
Nurses and patient care technicians have the responsibility of transferring patients from
many different locations, sometimes several times a day. Every time a transfer occurs there is a
possibility for patient harm. According to Anderson, Dolansky, Damato, and Jones (2015) In the
hospital, falls are one of the most common adverse events leading to injury, frequently resulting
in longer lengths of stay and increased costs, and emotional harm. Even though many falls do
not result in injury, those that do are often serious injuries and cost the hospital a substantial
amount of money (Anderson et. al., 2015).
In order to monitor and decrease the rate of falls, it is necessary for the nursing staff to
report these incidents. However, the fear of blame and retaliation, the sense of guilt, the lack of
support by supervisors, and lack of legal frameworks to protect nursing staff often discourage
nurses from disclosing these adverse events (Larizgoitia, Bouesseau, & Kelley, 2013). Hospitals
cannot better their incident preventions if they do not know about the true number and nature of
falls. This situation is currently leading to worse patient outcomes.
Background
I worked this summer as a Rehabilitation Care Tech and I was assigned to sit one-on-one
with a patient. When my patient was in therapy, I walked past another room and saw the call
light on and went in to assist. The patient reported that she needed to go to the bathroom. She
weighed about 260 pounds and the sign above the bed stated that her toileting status was the use
of a bedpan. She stated that her therapist recently had helped her pivot to the toilet and she
would rather use the toilet.
After setting up the wheelchair next to the toilet, I used the patients gait belt to lift her
up. As I picked her up the patients legs collapsed and she could not stand. I then began to lose

WHEN YOUR BRAIN BECOMES A FALL RISK

my balance and fell slightly backward. I was able to get one of my feet behind me and lowered
the patient to the floor safely. Once the patient was on the floor, I grabbed the gait belt,
repositioned myself, and lifted her back up into the wheelchair safely. I asked the patient
repeatedly, Are you OK? She responded, Yeah. She did not report any pain, did not hit her
head, and acted like nothing had happened.
I then ran outside, knowing that I should go tell the nurse or the tech that I lowered a
patient to the floor, but instead I asked a tech if she could help me transfer this patient. The tech
asked if everything was OK, and I responded, Yes! This patient is just a hard transfer. Before I
could go back in to assist with the transfer, I was told that my patient had returned from therapy
and could not be left alone. I returned to my assigned patient. I sat in the room and contemplated
my decision not to tell the nurse. After my shift, I spoke with my mom, who works in
administration at the hospital, and asked her what I should do. She told me I should immediately
tell the assigned nurse and also log a patient safety event report. I did both.
There are many different responses I could have taken instead of the one that I had chosen
initially. The best alternative response to this situation was to immediately tell the nurse, as soon
as the incident occurred.
I believe that this situation initially caused me moral distress and later on caused me to be
in a moral dilemma. I first experienced moral distress because the right thing was to tell someone
what happened, but the pressure and shame kept me from saying anything immediately. I was
then faced with two options, which put me in a moral dilemma. My first option was to tell the
nurse and possibly get reprimanded, lose the confidence of my coworkers, and possibly make my
mom look bad. My second option was to not tell the nurse. That way I would not lose any
confidence in my coworkers.

WHEN YOUR BRAIN BECOMES A FALL RISK

Methods/findings
The James Madison University Eight Key Questions reflect the best of humanitys
ethical reasoning traditions (Eight Key Questions (8KQ)). The Madison Collaborative has
operationalized these questions so they can be used as prompts at the point of decision making
(Eight Key Questions (8KQ)). The questions cover the categories of fairness, outcomes,
responsibilities, character, liberty, empathy, authority, and rights. Each question can serve as a
moral compass that can guide me when making difficult decisions and help to ensure moral
distress does not occur.
I could have used these Eight Key Questions to help me make a smarter decision in my
time of moral distress. In regard to fairness, by not saying anything initially, I was only looking
out for myself and not for the patient. The short-term outcomes include the patient possibly
receiving a minor hematoma and myself walking away with no consequence. The long-term
outcomes could include the hospital not having an accurate number of safety incidences or the
patient may have sustained an intracranial bleed or worse. Within the category of responsibility, I
had the obligation according to hospital policy to report any sort of safety incident. In all aspects
of authority, whether it is God, the law, supervisors, or hospital policies, I was expected to tell
someone about this safety event. Character to me means I should have integrity. This means I
would have immediately told the nursing staff. Liberty means respect for personal autonomy. I
needed to speak for the patient and tell the truth to ensure the best outcome. If I were to observe
empathy, I would want the best outcome and care for the person I cared deeply about. Therefore,
I would have told personnel involved in that patients care. Human rights and basic autonomy
apply. The patient would want me to report this to achieve the best care, by not reporting this
event I am taking that right away from this patient.

WHEN YOUR BRAIN BECOMES A FALL RISK

All of these eight questions could have altered the timeliness of the outcome of this event.
Another guideline that could have helped me in the foresight of my decision is the American
Nurses Associations Code of ethics for nurses with interpretive statements. The second
provision of this code states that the nurses primary commitment is to the patient, whether an
individual, family, group, community, or population (American Nurses Association (ANA),
2015). It further states that the nurse should ensure the patients safety and promote patients
best interests (American Nurses Association (ANA), 2015). By examining this code of ethics I
should have acted sooner. I should have continued my commitment to the patient and reported
this incident to the nurse, when it happened, not at the end of my shift.
Conclusion
If I could be placed in that situation again I would have done many things differently. I
would have stuck to my integrity. I would have told the tech that I first saw about the incident
that occurred. I would have communicated to the tech that I had to sit with my assigned patient,
but to tell the nurse as soon as possible. Lastly, I would have made sure that the charge nurse
knew of the incident before I reported off my shift.
This could also be generalized to the entire nursing profession. The patient I had lowered
to the floor was back in her chair just as she was before I tried to transfer her. I could have left
her there and received no consequence. The lesson that all nursing staff can take from this is that
integrity builds more character than fearing retribution. Always being forthcoming and patient
safety information allows for better patient outcomes. By stepping forward for my actions I built
more character for myself. Every nurse should be concerned with this and take it with them
every day on the floor. Build a community of trust and keep your patients safe.

WHEN YOUR BRAIN BECOMES A FALL RISK

References
American Nurses Association (ANA). (2015). Code of ethics for nurses with interpretive
statements. Silver Spring, MD: Author.
Anderson, C., Dolansky, M., Damato, E. G., & Jones, K. R. (2015). Predictors of Serious Fall
Injury in Hospitalized Patients. Clinical Nursing Research, 24(3), 269-283.
doi:10.1177/1054773814530758
Eight Key Questions (8KQ). (n.d.). Retrieved November 10, 2015, from
https://www.jmu.edu/mc/8-key-questions.shtml
Larizgoitia, I., Bouesseau, M., & Kelley, E. (2013). WHO efforts to promote reporting of adverse
events and global learning. Journal Of Public Health Research, 2(3), 168-174.
doi:10.4081/jphr.2013.e29