According to the World Health Organization (WHO, 2012), falls are the second main cause of death by accident worldwide, representing one of the main unwanted accidents and a challenge to patient safety, care quality and therefore to clinical supervision in nursing. Clinical supervision as a dynamic, reflective and integrative process for nurses plays a key role in the assurance of quality in health and patient safety because it allows not only the development of nurses’ knowledge and skills but also their responsibility of the performance in clinical practice.
Quality of health care is simultaneously considered to be a right of the patient but also a duty of the health professionals (Idvall, Hamrin, Soo, & Unosson, 2001). In this way, the relevance of clinical supervision for nurses is huge as it is a formal process to improve quality of care, patient safety and increase personal satisfaction.
Falls are an indicator of quality in health. Identifying people at risk of falling is essential because the most important aspect of fall prevention is its anticipation (Morse, 2009). Chang et al. (2004) analyzed several interventions for fall prevention programs and concluded that the risk evaluation is the essential intervention and nurses are target professionals in the identification of people at risk of falling and in implementing interventions to prevent falls (Williams et al., 2007).
Clinical supervision for safety and quality of care
In nursing, the concept of clinical supervision, despite being relatively recent, has been targeted with different definitions for those who studied this area. However, some definitions have common aspects such as: safety, quality of care and reflection in, on and from practice.
Clinical supervision consists not only in the interaction with regular meetings between the supervisee and the supervisor to critically discuss, in a reflexive and structured way, a particular case or a situation arising from the practice, with the aim of identifying the problems and finding solutions, but is also a formal process of support and training of professionals and standardization of practice. Its maximum exponential is not only the satisfaction and the wellbeing of the professional but also the promotion of care with safety and quality, in the extent that it enhances the knowledge and skills of nurses.
In several institutions, a growing interest and importance around clinical supervision has been noticed. In addition, the growing concern over the safety and quality in healthcare has led to the appearance of accreditation organizations and external audit organizations, especially in the United States of America and in the United Kingdom (Fragata, 2006). These subjects are being increasingly discussed in health, as they are the pillars of the commitment and mission of hospitals, communities and caregivers (Abreu & Marrow, 2012). These concerns are reflected in the demand for programs that can reduce the limitations and dependency of patients, as well as in the development of infrastructures that will help to prevent errors and accidents. Currently in Portugal, many nursing schools have incorporated supervision as a course of post-graduate training (Abreu & Marrow, 2012).
The quality arises, then, as a requirement, an attribute and an inescapable dimension in the provision of health care. Associated with quality comes safety, that should be seen as a top priority in improving health care. Clinical supervision in nursing is a major promoter of personal, professional and human development through the use of processes of reflection and experimentation, with the objective to improve the quality of care (Abreu, 2007) but it is also considered a core element in the improvement of clinical standards, as well as an important tool in the development of quality in nursing care with a fundamental role in the prevention of clinical risk (Wash et al., 2003; Wood, 2004; Garrido, Simões & Pires, 2008). Effects of clinical supervision on the quality of care are a key aspect in the improvement of quality and, therefore, were defined as a target area by the WHO (Hyrkäs & Lethi, 2003). There is an inseparable relationship between clinical supervision in nursing, safety and quality of nursing care.
Fall risk and Morse Fall Scale
In studies conducted in the last few years, falls have been the leading cause of injury, an important cause of death and a serious public health problem because of the medical and economic consequences but also by the transformations entailing the level of health and the quality of life of the patients (Caldevilla & Costa, 2009). According to WHO (2012), falls are the second leading cause of accidental death worldwide, representing a major adverse event and one of the major challenges in the context of patient safety and in quality of care, therefore, they are considered as an object to study within the framework of clinical supervision in nursing.
Fall risk is a nursing diagnosis identified through the application of scales and the incidence of falls is an indicator of the quality of nursing care. The evaluation of the fall risk and implementation of preventive measures (in accordance with the identified risk), contribute to the control of this phenomenon and to minimize its impact, because the incidence of falls decreases when there is a measurement and evaluation of this indicator, since it allows the adequacy of nursing interventions to the specific needs of the patient (Reis et al., 2004).
Regardless the tool chosen for the fall risk assessment (as long as it is sensitive and specific for the population), its application is a fundamental resource for falls prevention (Hendrich, 2006). There are 47 instruments related to the fall risk assessment and only two have been identified as suitable, namely, the MFS and the STRATIFY (Dempsey, 2008). Oliver et al. (2004) also identified these two instruments as well validated for assessing the fall risk. Nevertheless, the MFS reveled to have a better internal consistency (Cronbach’s alpha value - 0.72), good specificity (72.8%) and acceptability (Chapman et al., 2011). Furthermore, the MFS has been widely used and tested, and proved to have high sensitivity and specificity (O’Connell & Myers 2001; Myers & Nikoletti 2003; Ganz et al., 2013).
In Portugal, most of the hospitals use scales to assess the fall risk but some of them need to be translated and validated for the Portuguese population.
Janice Morse, author of the Morse Falls Scale, began the development of the scale with a pilot project in 1985. In 1987, she published the article "Development of a Scale to Identify the Fall-Prone Patient" (Morse, Morse, Tylko, 1989) and in 1997, the book "Preventing Patient Falls" was published. This book suffered a revision in its second edition in 2009. The scale is being applied internationally and has been widely tested. In Portugal, it is used in several hospitals and the Portuguese General Directorate of Health indicates the need to assess the fall risk as an appropriate and personalized preventive intervention (Direção Geral de Saúde [DGS], 2011).
The MFS consists of six items with two or three possible answers for each (with different scores for each possibility). According to the performed evaluation, the total of the scores in each of the six items, results in a global score that indicates the fall risk. This score ranges from 0 to 125 points.
Caldevila, M., & Costa, M. (2009). Quedas dos idosos em internamento hospitalar: Que passos para a enfermagem? Revista Investigação em Enfermagem, 19, 25-28
World Health Organization (WHO) (2012). Falls. Retrieved from http://www.who.int/mediacentre/factsheets/fs344/en/>
Reis, E.A.A, Denser, C.P.A.C., Minatel, V.F., & Bork, A.M.T. (2004). Definição de Indicadores de Assistência de Enfermagem a partir dos Dados Mínimos. Retrieved from http://www.sbis.org.br/cbis9/arquivos/730.doc
Hendrich, A. (2006). Inpatient Falls: lessons from the field. Patient Safety & Quality Healthcare, May-Jun, 26-30
Dempsey, J. (2008). Risk assessment and fall prevention: Practice development in action. Contemporary Nurse, 29, 123-134
Oliver, D., Daly, F., Martin, F. C., & McMurdo, M. E. T. (2004). Risk factors and risk assessment tools for falls in hospital in patients: a systematic review. Age and Ageing, 33, 122-130. doi: 10.1093/ageing/afh017
O’Connell, B., & Myers, H. (2001). A failed fall prevention study in an acute care setting: lessons from the swamp. International Journal of Nursing Practice, 7, 126-130. doi: 10.1046/j.1440-172X.2001.00300.x
Chapman, J., Bachand, D., & Hyrkäs, K. (2011). Testing the sensitivity, specificity and feasibility of four falls risk assessment tools in a clinical setting. Journal of Nursing Management, 19, 133-142. doi: 10.1111/j.1365-2834.2010.01218.x.
Direção Geral de Saúde (DGS) (2011). Prevenção e gestão de quedas e lesões por quedas. Departamento da Qualidade na Saúde. Retrieved from http://www.dgs.pt/ms/8/pagina.aspx?codigoms=5521&back=1&codigono=001100150185AAAAAAAAAAAA>
Morse, J. (2009). Preventing Patient Falls: Establishing a fall intervention program. 2nd ed., New York. Springer Publishing Company