Original Article
The Nurse as Bricoleur in Falls Prevention: Learning from a Case Study of the Implementation of Fall Prevention Best Practices Helen Kirkpatrick, RN, MScN, MEd, PhD • Sheryl Boblin, RN, PhD • Sandra Ireland, RN, MSc, PhD • Kim Robertson, RN, MScCH
ABSTRACT Keywords bricoleur, fall prevention, patient falls, PARiHS framework, nursing, case study, evidence-based practice
Background: Falls prevention in “real-life” clinical practice is a complex undertaking. Nurses play an active and essential role in falls prevention. Aim: This discussion paper presents a picture of the nurse as a bricoleur in falls prevention, requiring knowledge in many areas and the ability to perform multiple diverse tasks. Methods: Building on a qualitative case study with nurses at various levels in three acute care facilities, this paper posits that the concept of nurse as bricoleur has the potential to broaden our understanding of the complexity of falls prevention. Findings: The nurse as bricoleur within the Promoting Action Research in Health Services framework as the provider of person- or patient-centered evidence-based care is conceptualized. Within this framework, the nurse uses his or her professional knowledge or clinical experience while considering research, local data, and information, and the patient’s experience and preferences to provide this care, the bricolage. Each of these areas is discussed as well as the impact on the nurse when a fall does occur. Linking Evidence to Action: Recognizing this complexity of the nurses’ world has important implications for both service delivery and education, including preparation of students, and the implementation of new organizational initiatives and supports for nurses when falls do occur despite the best efforts of all involved.
INTRODUCTION Nurses routinely practice in increasingly complex environments. Rankin (2009) recommends we “pay attention to a nuanced and complex understanding of what nurses actually do,” and recognize “nurses’ expert knowing about the ‘churn’ of a day-to-day practice” (p. 276). However, the cognitive and emotional work required of nurses in these environments is often unrecognized and undervalued at higher organizational levels. Hamilton and Campbell (2011) state that all knowledge has a standpoint, and differentiate direct care knowledge from boardroom knowledge. Recognition of its complexity is important but often gets constructed quite differently as it reaches higher levels, as “boardroom knowledge” (p. 281). Nonetheless, there is increasing nursing research focusing on understanding the real-life experience of nurses practicing in complex environments: public health nursing practice contextualizing “risk” with “high-priority” families (Browne, Doane, Reimer, MacLeod, & McLellan, 2010); home care nurses dealing with complexity and contradiction (Skott & Lundgren, 2009); ethical
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practice within the complexities of everyday practice (Doane, Storch, & Pauly, 2009); and the actual practice of nurses in falls prevention (Rush et al., 2008; Stenberg & Wann-Hansson, 2011). The ideas presented in this discussion paper originated during a qualitative case study conducted by the authors within three acute care hospitals in Southern Ontario, Canada (Ireland, Kirkpatrick, Boblin, & Robertson, 2013). This foundational research examined the implementation of the Best Practice Guideline Prevention of Falls and Fall Injuries in the Older Adult (Falls BPG) published by the Registered Nurses Association of Ontario (RNAO, 2005, revised 2011). During focus groups and individual interviews, nurses discussed the complexity of their experiences with patient falls and fall prevention, and reviewed the evidence around guideline implementation. As the iterative process of qualitative data collection and analysis progressed, we became enthralled with how the concept of nurse as “bricoleur” resonated with our findings and enriched our understanding of the role of the nurse participants. Gobbi
Worldviews on Evidence-Based Nursing, 2014; 11:2, 118–125. C 2014 Sigma Theta Tau International
Original Article (2005) describes the nurse bricoleur as an individual who is knowledgeable in many areas, and adept at performing multiple, diverse tasks. Nurse bricoleurs give something of themselves, drawing on bits and pieces from many sources, and use whatever resources are available to deal with the known and unknown to create a “bricolage,” whether at an institutional or individual patient level. In this context, the bricolage is the provision of fall prevention practice.
THE FOUNDATIONAL RESEARCH This paper discusses the concept of nurse as bricoleur in the context of the foundational research study, building on two previous publications (Boblin, Ireland, Kirkpatrick, & Robertson, 2013; Ireland et al., 2013). The first publication details the actual research and findings (Ireland et al., 2013); the second focuses on the use of Qualitative Case Study methodology, Stake’s (1995) constructivist approach in particular (Boblin et al., 2013). The three participating hospitals were Registered Nurses’ Association of Ontario (RNAO) Best Practice Spotlight Organization (BPSO) candidates who had committed to implementing the Falls BPG. They were university-affiliated, and ranged in size from 300 to 900 beds. Numbers of nursing staff (registered nurses and registered practical nurses) ranged from 800 to 3400. To capture the essence of the complex processes of the Falls BPG implementation, a qualitative, single case study methodology was used (Stake, 1995). Data included documents, artifacts, observation of environments and Web sites, focus groups, and individual interviews with key informants. Key informants (N = 95) were primarily nurses at multiple levels of the organizations: point-of-care nurses (n = 41) and executives (n = 7). The remainder (n = 47) were advanced practice nurses, educators, managers, and other disciplines. Research Ethics Board approval was received from the hospitals and their academic affiliates. Following completion of the study, all three were successful in receiving their BPSO designation and met Accreditation Canada (2009) standards for the implementation of fall prevention strategies. Our study findings echoed other research in recognizing the complexities inherent in implementation of fall prevention in “real-life” clinical practice (Oliver et al., 2007; Rush et al., 2008; Stenberg & Wann-Hansson, 2011). We concluded that Falls BPG implementation was a diverse and complex activity, ideally suited for the involvement of nurse bricoleurs in a variety of organizational and point-of-care roles, who acted as facilitators in the multifaceted process of changing practice in fall prevention (Ireland et al., 2013). Although this discussion paper focuses primarily on nurses at the point-of-care, reference is made to nursing leaders in their facilitative roles in fall prevention.
THE BRICOLEUR The concept of bricoleur and bricolage was first introduced by Levi-Strauss (1966) in the mid-1960s, and has been further developed with the concept of researcher as bricoleur (Bazeley, Worldviews on Evidence-Based Nursing, 2014; 11:2, 118–125. C 2014 Sigma Theta Tau International
1999; Doane et al., 2009; Kincheloe, 2001, 2005) and school leader as bricoleur (Jenlink, 2006). The concept of nurse as bricoleur is gaining traction. Gobbi (2005) identified several characteristic features of nurse bricoleurs: “ . . . they manage complex, large and diverse tasks with the tools at hand; they get the job done, even if it becomes a different one en-route; they put something of themselves into their care which is particularized to the person concerned; they are multiskilled and reflexive; and they have the capacity for ingenuity and inventiveness” (p. 124). Nurses act as bricoleurs in many different work environments, and making do with what is available is a universal nursing trait (Aagard, 2009). The nurse as bricoleur draws upon a heterogeneous collection of fragments from multiple sources, which are deconstructed and then reconstructed in the context of working with an individual patient (Warne & McAndrew, 2009). Jenlink (2006) described today’s school leader as a bricoleur because they are confronted with countless complex problems reflecting the increasing diversity of a changing society, the press of political agendas, and increasing public expectations. These characteristics are also descriptive of today’s healthcare environment, with the additional focus on evidence-based care and patient safety. However, inclusion of evidence-based practice (EBP) within traditional care delivery models can intensify rather than simplify nursing care. Making use of evidence viable within existing models of care delivery may require “out of the box” innovative thinking to further the initiative while containing costs (Donley, 2005). Pressures on nursing leaders to address these and other competing needs were clear in the foundational study. Extensive mergers and restructuring throughout Ontario had taken the focus off patient safety. However, the pendulum was swinging back toward patient safety. In all three hospitals, nurse leaders acting as bricoleurs had to balance these shifting priorities. One nurse leader characterized her role as being there to “kick the boulders out of the way” (Ireland et al., 2013).
THEORETICAL FRAMEWORK Application of the Promoting Action Research in Health Services (PARiHS) framework was useful for the foundational study (Rycroft-Malone et al., 2004). The framework was developed to help understand the elements that contribute to successful implementation of evidence into practice in healthcare settings. It has been used as a practical and conceptual heuristic for researchers and clinicians to frame best practice (Kitson, Harvey, & McCormack, 1998). The framework had been used successfully by one of the authors in providing in-depth professional development opportunities for staff nurses. Its recognition of the complexity and multiple sources of evidence influencing the implementation of best practices helped to conceptualize the study, considering both leadership and point-of-care staff perspectives. The framework was used in developing the interview guide that included prompts to elicit both the context and history of fall prevention and health
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The Nurse Bricoleur in PARiHS Framework EVIDENCE •Research •Clinical experience •PaƟent experience •Local data/informaƟon
Sources Of Evidence
Research
FACILITATION
CONTEXT
•Purpose •Role •Skills & aƩributes
•Culture •Leadership •EvaluaƟon
Professional knowledge/ clinical experience
Nurse bricoleur provides person/paƟent centered evidence-based care
"Local" data & informaƟon
PaƟent experience & preferences
Adapted from: RycroŌ-Malone, J., Seers, K., Titchen, A., Harvey, G., Kitson, A., & McCormack, B. (2004). What counts as evidence in evidence-based pracƟce? Journal of Advanced Nursing, 47 (1), 81-90.
Figure 1. The Nurse Bricoleur in PARiHS Framework.
care within the organizations, and a focus on the roles of leadership in planning and point-of-care staff in implementation. It was revisited in the analysis phase, guiding us to recognize and categorize findings, such as the “shifting sands” context in which nurses function, and the complexity nurse bricoleurs face in implementing best practices in multiple patient populations and with limited resources. The PARiHS framework also helped us to understand the complexity of the change processes involved in implementing evidence into practice. It certainly brought into the forefront the complex challenges faced by nurse bricoleurs in the integration of evidence into practice (Boblin et al., 2013; Ireland et al., 2013). According to the PARiHS framework, successful implementation of EBPs is a function of the relationships among the nature of the evidence, the quality of the context for coping with change, and the type of facilitation required for a successful change process (Kitson et al., 1998, 2008; Rycroft-Malone et al., 2004). Four sources of evidence intersect to shape person- or patient-centered, evidence-based care: (a) research, (b) professional knowledge or clinical experience, (c) patient experience and preferences, and (d) “local” data and information (Rycroft-Malone et al., 2004). We conceptual-
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ized the nurse who provides this person- or patient-centered, evidence-based care as the bricoleur (see Figure 1). Nurse bricoleurs must simultaneously assess for, understand, and integrate all of these sources of evidence if they are to be successful in shaping the provision of person- or patient-centered, evidence-based care.
SOURCES OF EVIDENCE AND THE NURSE AS BRICOLEUR This discussion focuses on the interaction that occurs among the sources of evidence and the nurse bricoleur using examples from the foundational study. In addition, the impact of patient falls on the nurse, and the yin and yang of implementing fall prevention in “real-world” clinical practice are discussed. Yin and yang is a Chinese concept, wherein polar opposites are interconnected: opposites that exist in relation to each other. Research increasingly supports the claim that implementing evidence into practice is a complex, multifactorial process, not an event (Rycroft-Malone, 2010). To practice evidencebased, person-centered care, practitioners must use and integrate multiple sources of knowledge—a jigsaw—but how these Worldviews on Evidence-Based Nursing, 2014; 11:2, 118–125. C 2014 Sigma Theta Tau International
Original Article are melded together in real-time clinical decision making is still virtually unknown. Furthermore, these processes are not acontextual, but occur within a complex, multifaceted clinical environment (Rycroft-Malone et al., 2004). This practitioner is the bricoleur; “Hence the nurse, as scientist, seeks to analyze and possibly change practice through investigation, whereas the nurse as bricoleur would alter the events and adjust the tools to create practice” (Gobbi, 2005, p. 121). Complex environments require multidimensional implementation strategies. These strategies need to address barriers related to the individual practitioner, the social context, and organizational and environmental contexts, tailoring them to different groups of stakeholders, including nursing staff, project leaders, and administrators (Ploeg, Davies, Edwards, Gifford, & Miller, 2007). In the foundational study, this complexity related not only to the nature of the settings, but extended also to the characteristics of the patients and the nature of nursing work itself—the yin and yang of clinical practice. What appeared on the surface as a simple process of implementing the Falls BPG created tensions when applied to individual patients at the point-of-care (Ireland et al., 2013).
Research This research focused on implementation of the RNAO Falls BPG (RNAO, 2005, revised 2011). Therefore, the evidence in that BPG was the basis of the initiatives at all three hospitals.
Local Data and Information In the 10 years prior to the foundational study, nurses and hospitals faced considerable challenges, including a new College of Nurses of Ontario (CNO) practice guideline requiring nurses to rethink their practice of using bed rails to restrain patients at risk for falls (CNO, 2009). With the changes in regulation regarding restraints, the importance of alternatives to restraints was a frequently expressed concern—the yin and yang of patient safety (restraints) versus supporting patient independence. This was a specific issue for ultimate discharge disposition, since long-term care facilities would not accept patients who required restraints. A point-of-care staff nurse reported that, “One patient fell six times because he was kept out of restraints to aid in placement on discharge.” Concerns with workload issues were expressed by participants at all levels, and in all the organizations. Several leaders spoke of fall rates dependent on staffing, acuity of patients, skills mix, and levels of experienced versus inexperienced staff. Workload issues meant lack of time. This reality set the stage prompting nurses to “alter the events and adjust the tools to create practice” (Gobbi, 2005, p. 121). One emergency department manager used volunteers and nursing students to increase observation. Volunteers were not involved with patient care but as they performed other activities they observed the unit and called nurses if needed for an at-risk patient trying to get up— more eyes on the patient. This is an example of the nurse as bricoleur making do, altering events, and adjusting tools to create practice (Gobbi, 2005). It also reflects Donley’s (2005) “out Worldviews on Evidence-Based Nursing, 2014; 11:2, 118–125. C 2014 Sigma Theta Tau International
of the box” thinking, to further falls prevention and to protect patients while containing costs.
Professional Knowledge and Clinical Experience Nurse bricoleurs worked to adapt the environment to prevent patient falls. The patient’s location on the unit could affect the falls risk—too far from the desk or a high observation area increased the risk. Point-of-care staff described moving at-risk patients to the nurses’ station “where we can keep an eye on them,” while worrying about how well they slept there at night. The first hour of the day shift was then spent returning patients to their rooms. The availability of resources varied between hospitals and units, such as high–low beds and new exit alarm technology. Equipment shortages were a chronic problem for point-of-care nursing staff. They were reluctant to loan special equipment, as it might not be returned. Nurses described cluttered environments, and equipment that did not work correctly, commodes with wobbly wheels, call bells that were too short, and telephone cords that were too long. In tightly cramped bedside environments, mobility aides, such as walkers and canes, contributed to clutter and became environmental hazards. Bathrooms were a frequent concern. Nurses repeatedly described their fear of patients falling in bathrooms and how the lack of appropriate staffing and equipment contributed to falls. The involvement of families in fall prevention varied with the different sites and programs. Tools and artifacts helped with engaging families about falls prevention, such as a falls alert sign at the head of the bed. One participant noted, “Signs provided a teaching opportunity for staff with families about needing help to get patients up—more aware of their surrounding— wet floors, sedation.” One program had a contest to identify falls risks in the area, a contest in which both patients and families participated. At some sites, family members were encouraged to stay with patients; at others personal support workers were used as sitters rather than families. Some nurses noted that roommates helped watch patients. Point-of-care staff asked legitimate questions about measurement and evaluation. What needed to be documented was an important concern. They asked, “Does everything need to be documented? Do universal measures need to be documented? Or only additional and individualized strategies if the person is identified as high risk?” They questioned the validity of using the metric of fall rates to evaluate their practice if all precautions had been in place at the time of the patient’s fall. Generally speaking, point-of-care nurses were not familiar with their unit’s falls data, often expressing confidence that their manager was aware of it. They were more likely to be aware of audits. Where audits were completed, some facilities used staff to complete the audits and some used students.
Patient Experiences and Preferences Although the RNAO had clearly situated the Falls BPG within an integrating patient preferences paradigm, it also anticipated the tensions between the need to encourage and respect patient
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autonomy and independence, and provider concerns for patient safety and liability. Addressing these tensions was more difficult to implement than to value in the reality of clinical practice. On some units, a combination of short staffing and riskladen environments resulted in the need for staff to continue to ask for orders to restrain patients, leaving everyone feeling the yin and yang between efforts and challenges and generally unsatisfied with the support received or the process taken to resolve the problem. Nurses gave examples of the tension between safety and autonomy, taking people from familiarity and increasing risk. For example, “one client had gait issues but wanted to shower himself. He slipped in the water and fell.” Families were an important resource, but difficulties were also identified. There were concerns expressed that families might not leave falls precautions in place when they left, or if too many families stayed, how they could be accommodated. Tensions and frustrations resulted at the point-of-care when, in spite of the information that had been provided, patients continued to take risks and fall. Many point-of-care nurses spoke of health teaching, informing patients or families of falls risks and what to do. However, despite instruction, they talked about patients who would not listen and got out of bed for various reasons: patients do not want to bother the nurse; lack of staff to respond quickly so patients tire of waiting and try to do it for themselves; in new and unfamiliar environments, some patients insisted on maintaining their privacy and autonomy in personal care. Some patient groups were thought to be particularly challenging, in spite of the best efforts of staff. Patients who were cognitively intact but had recent amputations forgot their limitations; one patient forgot that he had an amputation and got up and split open his stump wound. Younger patients who were risk takers before hospitalization continued to take risks, putting them at risk for falls. Some point-of-care nurses also noted that many patients do not report their falls. In one rehabilitation focus group, participants reported that many patients will deny a fall—they are embarrassed and do not want to lose their independence. Rehabilitation programs by definition promote independence, but this left staff without knowledge of future risk or the ability to intervene to reduce it.
Impact of a Fall on the Nurse Fall prevention required nurses to give something of themselves (Gobbi, 2005) in preventing patient falls; sometimes that resulted in an emotional cost to them. In spite of attention to all these components parts, a sense of personal responsibility was projected by point-of-care staff as they described patient falls that remained fresh in their memories. They talked about the emotional impact patient falls had on them. Although nurses did not trivialize or minimize the seriousness of a patient fall, they often expressed a sense of inevitability when they talked about patient falls. They did not agree that the number of patient falls reflected their efforts to prevent them. There was a prevailing sense that some patient falls were just beyond their control. Unpredictable changes in the patient’s condition could
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contribute to falls, even with adequate supervision. Antiquated patient bathrooms and other environmental risk factors left nurses feeling responsible for falls that they could not control. One nurse described a patient who had sloughing of skin due to a drug reaction, and the many creams applied made her slippery. She slid in the bathroom and fell while the nurse was standing next to her; the patient was attempting to help herself despite instructions to the contrary. Nurses reported questioning themselves: “was there more that I could do?” But although they questioned themselves, and felt horrible after a fall, some also talked of feeling blamed. The process around postfall reviews did not feel “friendly,” and nurses were fearful of the outcome. In spite of the hospitals’ patient safety philosophies of creating a “no blame” culture, staff continued to feel that they were being held responsible for falls. This was particularly felt by staff who worked on units that were perceived to be chronically short staffed and under equipped. Nurses questioned that they have made the assessment and identified an issue but do not have the resources to implement—what is their liability? “Nurses always feel guilty when things do not go well.”
DISCUSSION This paper adds to a growing body of knowledge related to understanding experiences of nurses working in complex practice situations and, in particular, in preventing falls. It values the complex role of the nurse in real-world practice—the bricoleur, who creates practice through altering events and adjusting tools (Gobbi, 2005). Gobbi (2005) has introduced dilemmas associated with evaluating the knowledge, evidence, and practice generated by the bricoleur in determining “intellectual rigor and/or their practical application to a context for which they have not been designed” (p. 123). The concept of nurse as bricoleur in fall prevention presented in this paper does not attempt to reflect an individual’s level of expertise or evaluate the practice that was implemented. Both novice and expert nurse participants functioned in complex environments. Expert nurse bricoleurs may have integrated a deeper level of professional knowledge and clinical experience, providing a larger repertoire from which to make do, alter events, and adjust tools to create and evaluate practice. Novice nurse bricoleurs may have relied on a more limited experience, expert advice, and academic knowledge to create and evaluate practice. In the process of member checking, performed to confirm the findings of the foundational research, we introduced the concept of nurse as bricoleur to nurse participants at the three study sites. Nurses at all levels were drawn to its ability to explain their role in fall prevention, recognizing and confirming the complexity, and valuing the multitasking of everyday practice. Workload and staffing levels, local data, the stressful impact on the nurse of a fall, and the yin and yang inherent in falls prevention also were key issues in two other qualitative studies that examined the experiences of point-of-care staff in falls Worldviews on Evidence-Based Nursing, 2014; 11:2, 118–125. C 2014 Sigma Theta Tau International
Original Article prevention with similar findings (Rush et al., 2008; Stenberg & Wann-Hansson, 2011). In Rush et al.’s (2008) study with nurses, staffing was an important issue. Poor staffing prevented nurses from being vigilant in making rounds and direct contact, although adequate staffing “gave eyes and ears to high-risk patients” (p. 363). Patients calling for assistance when nurses were otherwise occupied left staff unaware of changes. Unfamiliar and cluttered environments were obstacles to falls prevention. Geographic layout was important in knowing the safety of patients. Patient characteristics contributed to the yin and yang—fiercely independent high-risk patients, patients desiring independence, led to a tension between safety and risk taking and independence. When falls did occur, it was a major stressor influenced by circumstances, extent of injury, consuming one’s day, concerns about the possibility of reprisals, lawsuits, and liability. Acceptance of patient falls “was not a giving up but an acknowledgement that often patient falls were beyond their control” (p. 364). Similar issues were identified by Stenberg and WannHannson (2011), in a study with nurses, physicians, physiotherapists, and occupational therapists. The physical environment (e.g., narrow bathrooms) and equipment, patient distance from the nurses’ station, and staff adequacy were all important issues. Personnel and frequent use of temporary employees were additional problems. Both nurses and physicians experienced a fear of reprisals and reprimands. When two recommendations were contradictory, this was experienced as an obstacle: prevent the patient from falls by using a restraint but also consider the ethical aspect and patient integrity. This dichotomy again reflects the yin and yang of falls prevention. The seemingly simple process of collaborating with patients and families to create a falls prevention plan of care based on the Falls BPG became incredibly complex in practice. Research related to patient experience of falls and their prevention confirms this complexity. In a concept analysis of partnership in the professional–patient relationship, Hook (2006) identified that the patient is recognized as “expert” in, and ultimately responsible for managing their own care, but the mechanism(s) for effectively achieving this partnership is unknown. Several qualitative studies of older persons have addressed the patient experience in relation to falls and this too is a complex phenomenon. In a study of older people’s experience of falls, Roe et al. (2008) concluded that assisting people to reflect on their falls and why they happened could help in preventing future falls, allay fear, boost confidence, and aid in rehabilitation. Yardley, Donovan-Hall, Francis, and Todd (2006) found that older persons do not reject suggestions because of ignorance about their risk of falling, but because it could threaten their autonomy and identity. From a study of older persons who had visited an emergency department after a fall, but had then opted not to employ a falls prevention strategy, Whitehead, Rundke, and Crotty (2006) recommended more focus on changing patients’ attitudes toward the intervention rather than on how the interventions should be delivered. Based on a literature review, clinical experience, and qualitative and quantitative data, Worldviews on Evidence-Based Nursing, 2014; 11:2, 118–125. C 2014 Sigma Theta Tau International
Yardley et al. (2007) promoted uptake of, and adherence to, falls prevention interventions among older people, which included public education, ensuring compatibility of interventions with a positive identity, and tailoring interventions to the individuals’ situation and values. A meta-ethnography of qualitative studies of older persons’ views on risk of falling and potential interventions confirmed this complexity (McInnes, Seers, & Tutton, 2011).
IMPLICATIONS Gobbi (2005) completed her paper with the hope that her ideas about the nurse bricoleur would provoke further debate about the realities of practice. It is our hope to contribute to that debate. As Rankin (2009) noted, it is important to pay attention to the actual, real-world work of nurses. Understanding the concept of bricoleur in the context of nursing allows us to recognize and value what nurses do in real-life practice in managing complex and dynamic patient care situations. This has implications for practice and education. At the practice level, the concept of bricolage is useful in furthering our understanding of the complexity of nursing practice. It honors that complexity and suggests that nurses justifiably modify their actions and their context, utilizing multiple sources of evidence-based knowledge. This is different from simply finding evidence and attempting to apply it; it also takes into account the different facts of the patient’s situation, the patient’s preferences, and the context of the institution in time and place. It helps us to understand the process that expert nurses use to “intuitively” decide what to do and the many facets that influence the perceptions of experience that lead to real-world clinical work. It provides a way of helping nurses to analyze and evaluate their thinking and decision-making processes so that they can better learn from themselves and communicate this thinking and action process to less experienced nurses. At the administrative level, the concept of nurse as bricoleur is useful, as it helps leaders when considering multiple aspects of a situation that need to be considered when contemplating the implementation of a change in practice. It will assist organizations to move thinking from blaming the nurse (even if not intentional) to recognizing the complexity of the environment and nurse thinking in the attempt to reduce falls. Although falls prevention appears to be a simple change in practice, this discussion has demonstrated the complexity involved. When planning to introduce a change, nurse administrators need to consider the knowledge of the nurses at the point-of-care, to assist them in analyzing what they are currently doing, and how they are considering multiple perspectives when deciding on a specific course of action. As Hamilton and Campbell (2011) identify, this would involve building on point-of-care nurses’ unique standpoint. Using the sources of evidence as a starting point in planning may facilitate change, by beginning the discussion with honoring and resourcing the complex decision-making process that the nurse will need to engage in to implement the care required.
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At the education level, the concept of bricoleur helps us to comprehend the complexity of real-world practice. Although beginning with single, simpler concepts, it is important for faculty to recognize the complex environments into which students and new graduates will move and to assist them to recognize this complexity in the practitioners they work with in their practicums. This paper contributes to expanding our understanding of expert nursing practice. The concept of nurse bricoleur moves us to a deeper understanding of the extent of nursing knowledge—the knowing and acting together that considers multiple factors simultaneously and moves to deliberate action in a seemingly instantaneous action. By better understanding the complexity of nursing practice, we can support and improve practice and ultimately improve patient experiences and outcomes. WVN
accreditation.ca/news-and-publications/publications/canadianhealth-accreditation-report/ Bazeley, P. (1999). The bricoleur with a computer: Piecing together qualitative and quantitative data. Qualitative Health Research, 9, 279–287. Boblin, S., Ireland, S., Kirkpatrick, H., & Robertson, K. (2013). Using Stake’s Qualitative Case Study approach to explore implementation of evidence-based practice. Qualitative Health Research, 23(9), 1267–1275. Brown, A., Doane, G., Reimer, J., MacLeod, M., & McLellan, E. (2010). Public health nursing practice with “high priority” families: The significance of contextualizing “risk.” Nursing Inquiry, 17(1), 26–37. College of Nurses of Ontario. (2009). Restraints. Retrieved from www.cno.org Doane, G., Storch, J., & Pauly, B. (2009). Ethical nursing practice: Inquiry-in-action. Nursing Inquiry, 16(3), 232–240. Donley, R. (2005). Challenges for nursing in the 21st Century. Nursing Economics, 23(6), 312–318.
LINKING EVIDENCE TO ACTION • Organizational initiatives meaningfully include nurses’ point-of-care knowledge to recognize the complexities of real-world practice. • At the practice level, there is a need for: ◦ supports for nurses when falls do occur, ◦ recognition of the complexity of including the patient experience and preferences, and ◦ timely provision of local data. • At the education level, faculty can assist students to recognize this complexity in the practitioners they work with in their practicums.
Author information Helen Kirkpatrick, BPSO Co-ordinator, St. Joseph’s Healthcare Hamilton, and Assistant Clinical Professor, McMaster University School of Nursing, Hamilton, ON, Canada; Sheryl Boblin, Associate Professor, McMaster University School of Nursing, Hamilton, ON, Canada; Sandra Ireland, Assistant Clinical Professor, McMaster University School of Nursing, Hamilton, ON, Canada; Kim Robertson, Risk Management Specialist, St. Joseph’s Health Care Hamilton, Hamilton, ON, Canada. Address correspondence to Dr. Helen Kirkpatrick, St. Joseph’s Healthcare Hamilton, West 5th Campus, B324, 100 West 5th, Hamilton, ON, L8N 3K7 Canada; [email protected] Accepted 23 June 2013 C 2014, Sigma Theta Tau International Copyright
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Original Article Ploeg, J., Davies, B., Edwards, N., Gifford, W., & Miller, P. E. (2007). Factors influencing best-practice guideline implementation: Lessons learned from administrators, nursing staff, and project leaders. Worldviews on Evidence-Based Nursing, 4(4), 210– 219.
Skott, C., & Lundgren, S. (2009). Complexity and contradiction: Home care in a multicultural area. Nursing Inquiry, 16(3), 223– 231.
Rankin, J. (2009). The nurse project: An analysis for nurses to take back our work. Nursing Inquiry, 16(4), 275–286.
Stenberg, M., & Wann-Hansson, C. (2011). Health care professionals’ attitudes and compliance to clinical practice guidelines to prevent falls and fall injuries. Worldviews on Evidence-Based Nursing, 8(2), 87–95.
Registered Nurses’ Association of Ontario (RNAO). (2005, revised 2011). Prevention of falls and fall injuries in the older adult. Retrieved from http://www.rnao.org Registered Nurses’ Association of Ontario (RNAO). (2009). Best practice spotlight organization. Retrieved from http://www.rnao. org. Roe, B., Howell, F., Riniotis, K., Beech, R., Crome, P., & Ong, B. N. (2008). Older people’s experience of falls: Understanding, interpretation and autonomy. Journal of Advanced Nursing, 6(36), 586–596.
Stake, R. (1995). The art of case study research. Thousand Oaks, CA: Sage.
Warne, T., & McAndrew, S. (2009). Constructing a bricolage of nursing research, education and practice. Nurse Education Today, 29, 855–858. Whitehead, C. H., Wundke, R., & Crotty, M. (2006). Attitudes to falls and injury prevention: What are the barriers to implementing falls prevention strategies? Clinical Rehabilitation, 20, 536–542.
Rush, K., Robey-Williams, C., Patton, L. M., Chanberlain, D., Bendyk, H., & Sparks, T. (2008). Patient falls: Acute care nurses’ experiences. Journal of Clinical Nursing, 18, 357–365.
Yardley, L., Beyer, N., Hauer, K., McKee, K., Ballinger, C., & Todd, C. (2007). Recommendations for promoting the engagement of older people in activities to prevent falls. Quality and Safety in Health Care, 16, 230–234.
Rycroft-Malone, J. (2010). Paying attention to complexity in implementation research (Editorial). Worldviews on Evidence-Based Nursing, 7, 121–122.
Yardley, L., Donovan-Hall, M., Francis, K., & Todd, C. (2006). Older people’s views of advice about falls prevention: A qualitative study. Health Education Research, 21(4), 508–517.
Rycroft-Malone, J., Seers, K., Titchen, A., Harvey, G., Kitson, A., & McCormack, B. (2004). What counts as evidence in evidence-based practice? Journal of Advanced Nursing, 47(1), 81–90.
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The Nurse as Bricoleur in Falls Prevention: Learning from a Case Study of the Implementation of Fall Prevention Best Practices Helen Kirkpatrick, RN, MScN, MEd, PhD • Sheryl Boblin, RN, PhD • Sandra Ireland, RN, MSc, PhD • Kim Robertson, RN, MScCH
ABSTRACT Keywords bricoleur, fall prevention, patient falls, PARiHS framework, nursing, case study, evidence-based practice
Background: Falls prevention in “real-life” clinical practice is a complex undertaking. Nurses play an active and essential role in falls prevention. Aim: This discussion paper presents a picture of the nurse as a bricoleur in falls prevention, requiring knowledge in many areas and the ability to perform multiple diverse tasks. Methods: Building on a qualitative case study with nurses at various levels in three acute care facilities, this paper posits that the concept of nurse as bricoleur has the potential to broaden our understanding of the complexity of falls prevention. Findings: The nurse as bricoleur within the Promoting Action Research in Health Services framework as the provider of person- or patient-centered evidence-based care is conceptualized. Within this framework, the nurse uses his or her professional knowledge or clinical experience while considering research, local data, and information, and the patient’s experience and preferences to provide this care, the bricolage. Each of these areas is discussed as well as the impact on the nurse when a fall does occur. Linking Evidence to Action: Recognizing this complexity of the nurses’ world has important implications for both service delivery and education, including preparation of students, and the implementation of new organizational initiatives and supports for nurses when falls do occur despite the best efforts of all involved.
INTRODUCTION Nurses routinely practice in increasingly complex environments. Rankin (2009) recommends we “pay attention to a nuanced and complex understanding of what nurses actually do,” and recognize “nurses’ expert knowing about the ‘churn’ of a day-to-day practice” (p. 276). However, the cognitive and emotional work required of nurses in these environments is often unrecognized and undervalued at higher organizational levels. Hamilton and Campbell (2011) state that all knowledge has a standpoint, and differentiate direct care knowledge from boardroom knowledge. Recognition of its complexity is important but often gets constructed quite differently as it reaches higher levels, as “boardroom knowledge” (p. 281). Nonetheless, there is increasing nursing research focusing on understanding the real-life experience of nurses practicing in complex environments: public health nursing practice contextualizing “risk” with “high-priority” families (Browne, Doane, Reimer, MacLeod, & McLellan, 2010); home care nurses dealing with complexity and contradiction (Skott & Lundgren, 2009); ethical
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practice within the complexities of everyday practice (Doane, Storch, & Pauly, 2009); and the actual practice of nurses in falls prevention (Rush et al., 2008; Stenberg & Wann-Hansson, 2011). The ideas presented in this discussion paper originated during a qualitative case study conducted by the authors within three acute care hospitals in Southern Ontario, Canada (Ireland, Kirkpatrick, Boblin, & Robertson, 2013). This foundational research examined the implementation of the Best Practice Guideline Prevention of Falls and Fall Injuries in the Older Adult (Falls BPG) published by the Registered Nurses Association of Ontario (RNAO, 2005, revised 2011). During focus groups and individual interviews, nurses discussed the complexity of their experiences with patient falls and fall prevention, and reviewed the evidence around guideline implementation. As the iterative process of qualitative data collection and analysis progressed, we became enthralled with how the concept of nurse as “bricoleur” resonated with our findings and enriched our understanding of the role of the nurse participants. Gobbi
Worldviews on Evidence-Based Nursing, 2014; 11:2, 118–125. C 2014 Sigma Theta Tau International
Original Article (2005) describes the nurse bricoleur as an individual who is knowledgeable in many areas, and adept at performing multiple, diverse tasks. Nurse bricoleurs give something of themselves, drawing on bits and pieces from many sources, and use whatever resources are available to deal with the known and unknown to create a “bricolage,” whether at an institutional or individual patient level. In this context, the bricolage is the provision of fall prevention practice.
THE FOUNDATIONAL RESEARCH This paper discusses the concept of nurse as bricoleur in the context of the foundational research study, building on two previous publications (Boblin, Ireland, Kirkpatrick, & Robertson, 2013; Ireland et al., 2013). The first publication details the actual research and findings (Ireland et al., 2013); the second focuses on the use of Qualitative Case Study methodology, Stake’s (1995) constructivist approach in particular (Boblin et al., 2013). The three participating hospitals were Registered Nurses’ Association of Ontario (RNAO) Best Practice Spotlight Organization (BPSO) candidates who had committed to implementing the Falls BPG. They were university-affiliated, and ranged in size from 300 to 900 beds. Numbers of nursing staff (registered nurses and registered practical nurses) ranged from 800 to 3400. To capture the essence of the complex processes of the Falls BPG implementation, a qualitative, single case study methodology was used (Stake, 1995). Data included documents, artifacts, observation of environments and Web sites, focus groups, and individual interviews with key informants. Key informants (N = 95) were primarily nurses at multiple levels of the organizations: point-of-care nurses (n = 41) and executives (n = 7). The remainder (n = 47) were advanced practice nurses, educators, managers, and other disciplines. Research Ethics Board approval was received from the hospitals and their academic affiliates. Following completion of the study, all three were successful in receiving their BPSO designation and met Accreditation Canada (2009) standards for the implementation of fall prevention strategies. Our study findings echoed other research in recognizing the complexities inherent in implementation of fall prevention in “real-life” clinical practice (Oliver et al., 2007; Rush et al., 2008; Stenberg & Wann-Hansson, 2011). We concluded that Falls BPG implementation was a diverse and complex activity, ideally suited for the involvement of nurse bricoleurs in a variety of organizational and point-of-care roles, who acted as facilitators in the multifaceted process of changing practice in fall prevention (Ireland et al., 2013). Although this discussion paper focuses primarily on nurses at the point-of-care, reference is made to nursing leaders in their facilitative roles in fall prevention.
THE BRICOLEUR The concept of bricoleur and bricolage was first introduced by Levi-Strauss (1966) in the mid-1960s, and has been further developed with the concept of researcher as bricoleur (Bazeley, Worldviews on Evidence-Based Nursing, 2014; 11:2, 118–125. C 2014 Sigma Theta Tau International
1999; Doane et al., 2009; Kincheloe, 2001, 2005) and school leader as bricoleur (Jenlink, 2006). The concept of nurse as bricoleur is gaining traction. Gobbi (2005) identified several characteristic features of nurse bricoleurs: “ . . . they manage complex, large and diverse tasks with the tools at hand; they get the job done, even if it becomes a different one en-route; they put something of themselves into their care which is particularized to the person concerned; they are multiskilled and reflexive; and they have the capacity for ingenuity and inventiveness” (p. 124). Nurses act as bricoleurs in many different work environments, and making do with what is available is a universal nursing trait (Aagard, 2009). The nurse as bricoleur draws upon a heterogeneous collection of fragments from multiple sources, which are deconstructed and then reconstructed in the context of working with an individual patient (Warne & McAndrew, 2009). Jenlink (2006) described today’s school leader as a bricoleur because they are confronted with countless complex problems reflecting the increasing diversity of a changing society, the press of political agendas, and increasing public expectations. These characteristics are also descriptive of today’s healthcare environment, with the additional focus on evidence-based care and patient safety. However, inclusion of evidence-based practice (EBP) within traditional care delivery models can intensify rather than simplify nursing care. Making use of evidence viable within existing models of care delivery may require “out of the box” innovative thinking to further the initiative while containing costs (Donley, 2005). Pressures on nursing leaders to address these and other competing needs were clear in the foundational study. Extensive mergers and restructuring throughout Ontario had taken the focus off patient safety. However, the pendulum was swinging back toward patient safety. In all three hospitals, nurse leaders acting as bricoleurs had to balance these shifting priorities. One nurse leader characterized her role as being there to “kick the boulders out of the way” (Ireland et al., 2013).
THEORETICAL FRAMEWORK Application of the Promoting Action Research in Health Services (PARiHS) framework was useful for the foundational study (Rycroft-Malone et al., 2004). The framework was developed to help understand the elements that contribute to successful implementation of evidence into practice in healthcare settings. It has been used as a practical and conceptual heuristic for researchers and clinicians to frame best practice (Kitson, Harvey, & McCormack, 1998). The framework had been used successfully by one of the authors in providing in-depth professional development opportunities for staff nurses. Its recognition of the complexity and multiple sources of evidence influencing the implementation of best practices helped to conceptualize the study, considering both leadership and point-of-care staff perspectives. The framework was used in developing the interview guide that included prompts to elicit both the context and history of fall prevention and health
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The Nurse Bricoleur in PARiHS Framework EVIDENCE •Research •Clinical experience •PaƟent experience •Local data/informaƟon
Sources Of Evidence
Research
FACILITATION
CONTEXT
•Purpose •Role •Skills & aƩributes
•Culture •Leadership •EvaluaƟon
Professional knowledge/ clinical experience
Nurse bricoleur provides person/paƟent centered evidence-based care
"Local" data & informaƟon
PaƟent experience & preferences
Adapted from: RycroŌ-Malone, J., Seers, K., Titchen, A., Harvey, G., Kitson, A., & McCormack, B. (2004). What counts as evidence in evidence-based pracƟce? Journal of Advanced Nursing, 47 (1), 81-90.
Figure 1. The Nurse Bricoleur in PARiHS Framework.
care within the organizations, and a focus on the roles of leadership in planning and point-of-care staff in implementation. It was revisited in the analysis phase, guiding us to recognize and categorize findings, such as the “shifting sands” context in which nurses function, and the complexity nurse bricoleurs face in implementing best practices in multiple patient populations and with limited resources. The PARiHS framework also helped us to understand the complexity of the change processes involved in implementing evidence into practice. It certainly brought into the forefront the complex challenges faced by nurse bricoleurs in the integration of evidence into practice (Boblin et al., 2013; Ireland et al., 2013). According to the PARiHS framework, successful implementation of EBPs is a function of the relationships among the nature of the evidence, the quality of the context for coping with change, and the type of facilitation required for a successful change process (Kitson et al., 1998, 2008; Rycroft-Malone et al., 2004). Four sources of evidence intersect to shape person- or patient-centered, evidence-based care: (a) research, (b) professional knowledge or clinical experience, (c) patient experience and preferences, and (d) “local” data and information (Rycroft-Malone et al., 2004). We conceptual-
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ized the nurse who provides this person- or patient-centered, evidence-based care as the bricoleur (see Figure 1). Nurse bricoleurs must simultaneously assess for, understand, and integrate all of these sources of evidence if they are to be successful in shaping the provision of person- or patient-centered, evidence-based care.
SOURCES OF EVIDENCE AND THE NURSE AS BRICOLEUR This discussion focuses on the interaction that occurs among the sources of evidence and the nurse bricoleur using examples from the foundational study. In addition, the impact of patient falls on the nurse, and the yin and yang of implementing fall prevention in “real-world” clinical practice are discussed. Yin and yang is a Chinese concept, wherein polar opposites are interconnected: opposites that exist in relation to each other. Research increasingly supports the claim that implementing evidence into practice is a complex, multifactorial process, not an event (Rycroft-Malone, 2010). To practice evidencebased, person-centered care, practitioners must use and integrate multiple sources of knowledge—a jigsaw—but how these Worldviews on Evidence-Based Nursing, 2014; 11:2, 118–125. C 2014 Sigma Theta Tau International
Original Article are melded together in real-time clinical decision making is still virtually unknown. Furthermore, these processes are not acontextual, but occur within a complex, multifaceted clinical environment (Rycroft-Malone et al., 2004). This practitioner is the bricoleur; “Hence the nurse, as scientist, seeks to analyze and possibly change practice through investigation, whereas the nurse as bricoleur would alter the events and adjust the tools to create practice” (Gobbi, 2005, p. 121). Complex environments require multidimensional implementation strategies. These strategies need to address barriers related to the individual practitioner, the social context, and organizational and environmental contexts, tailoring them to different groups of stakeholders, including nursing staff, project leaders, and administrators (Ploeg, Davies, Edwards, Gifford, & Miller, 2007). In the foundational study, this complexity related not only to the nature of the settings, but extended also to the characteristics of the patients and the nature of nursing work itself—the yin and yang of clinical practice. What appeared on the surface as a simple process of implementing the Falls BPG created tensions when applied to individual patients at the point-of-care (Ireland et al., 2013).
Research This research focused on implementation of the RNAO Falls BPG (RNAO, 2005, revised 2011). Therefore, the evidence in that BPG was the basis of the initiatives at all three hospitals.
Local Data and Information In the 10 years prior to the foundational study, nurses and hospitals faced considerable challenges, including a new College of Nurses of Ontario (CNO) practice guideline requiring nurses to rethink their practice of using bed rails to restrain patients at risk for falls (CNO, 2009). With the changes in regulation regarding restraints, the importance of alternatives to restraints was a frequently expressed concern—the yin and yang of patient safety (restraints) versus supporting patient independence. This was a specific issue for ultimate discharge disposition, since long-term care facilities would not accept patients who required restraints. A point-of-care staff nurse reported that, “One patient fell six times because he was kept out of restraints to aid in placement on discharge.” Concerns with workload issues were expressed by participants at all levels, and in all the organizations. Several leaders spoke of fall rates dependent on staffing, acuity of patients, skills mix, and levels of experienced versus inexperienced staff. Workload issues meant lack of time. This reality set the stage prompting nurses to “alter the events and adjust the tools to create practice” (Gobbi, 2005, p. 121). One emergency department manager used volunteers and nursing students to increase observation. Volunteers were not involved with patient care but as they performed other activities they observed the unit and called nurses if needed for an at-risk patient trying to get up— more eyes on the patient. This is an example of the nurse as bricoleur making do, altering events, and adjusting tools to create practice (Gobbi, 2005). It also reflects Donley’s (2005) “out Worldviews on Evidence-Based Nursing, 2014; 11:2, 118–125. C 2014 Sigma Theta Tau International
of the box” thinking, to further falls prevention and to protect patients while containing costs.
Professional Knowledge and Clinical Experience Nurse bricoleurs worked to adapt the environment to prevent patient falls. The patient’s location on the unit could affect the falls risk—too far from the desk or a high observation area increased the risk. Point-of-care staff described moving at-risk patients to the nurses’ station “where we can keep an eye on them,” while worrying about how well they slept there at night. The first hour of the day shift was then spent returning patients to their rooms. The availability of resources varied between hospitals and units, such as high–low beds and new exit alarm technology. Equipment shortages were a chronic problem for point-of-care nursing staff. They were reluctant to loan special equipment, as it might not be returned. Nurses described cluttered environments, and equipment that did not work correctly, commodes with wobbly wheels, call bells that were too short, and telephone cords that were too long. In tightly cramped bedside environments, mobility aides, such as walkers and canes, contributed to clutter and became environmental hazards. Bathrooms were a frequent concern. Nurses repeatedly described their fear of patients falling in bathrooms and how the lack of appropriate staffing and equipment contributed to falls. The involvement of families in fall prevention varied with the different sites and programs. Tools and artifacts helped with engaging families about falls prevention, such as a falls alert sign at the head of the bed. One participant noted, “Signs provided a teaching opportunity for staff with families about needing help to get patients up—more aware of their surrounding— wet floors, sedation.” One program had a contest to identify falls risks in the area, a contest in which both patients and families participated. At some sites, family members were encouraged to stay with patients; at others personal support workers were used as sitters rather than families. Some nurses noted that roommates helped watch patients. Point-of-care staff asked legitimate questions about measurement and evaluation. What needed to be documented was an important concern. They asked, “Does everything need to be documented? Do universal measures need to be documented? Or only additional and individualized strategies if the person is identified as high risk?” They questioned the validity of using the metric of fall rates to evaluate their practice if all precautions had been in place at the time of the patient’s fall. Generally speaking, point-of-care nurses were not familiar with their unit’s falls data, often expressing confidence that their manager was aware of it. They were more likely to be aware of audits. Where audits were completed, some facilities used staff to complete the audits and some used students.
Patient Experiences and Preferences Although the RNAO had clearly situated the Falls BPG within an integrating patient preferences paradigm, it also anticipated the tensions between the need to encourage and respect patient
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autonomy and independence, and provider concerns for patient safety and liability. Addressing these tensions was more difficult to implement than to value in the reality of clinical practice. On some units, a combination of short staffing and riskladen environments resulted in the need for staff to continue to ask for orders to restrain patients, leaving everyone feeling the yin and yang between efforts and challenges and generally unsatisfied with the support received or the process taken to resolve the problem. Nurses gave examples of the tension between safety and autonomy, taking people from familiarity and increasing risk. For example, “one client had gait issues but wanted to shower himself. He slipped in the water and fell.” Families were an important resource, but difficulties were also identified. There were concerns expressed that families might not leave falls precautions in place when they left, or if too many families stayed, how they could be accommodated. Tensions and frustrations resulted at the point-of-care when, in spite of the information that had been provided, patients continued to take risks and fall. Many point-of-care nurses spoke of health teaching, informing patients or families of falls risks and what to do. However, despite instruction, they talked about patients who would not listen and got out of bed for various reasons: patients do not want to bother the nurse; lack of staff to respond quickly so patients tire of waiting and try to do it for themselves; in new and unfamiliar environments, some patients insisted on maintaining their privacy and autonomy in personal care. Some patient groups were thought to be particularly challenging, in spite of the best efforts of staff. Patients who were cognitively intact but had recent amputations forgot their limitations; one patient forgot that he had an amputation and got up and split open his stump wound. Younger patients who were risk takers before hospitalization continued to take risks, putting them at risk for falls. Some point-of-care nurses also noted that many patients do not report their falls. In one rehabilitation focus group, participants reported that many patients will deny a fall—they are embarrassed and do not want to lose their independence. Rehabilitation programs by definition promote independence, but this left staff without knowledge of future risk or the ability to intervene to reduce it.
Impact of a Fall on the Nurse Fall prevention required nurses to give something of themselves (Gobbi, 2005) in preventing patient falls; sometimes that resulted in an emotional cost to them. In spite of attention to all these components parts, a sense of personal responsibility was projected by point-of-care staff as they described patient falls that remained fresh in their memories. They talked about the emotional impact patient falls had on them. Although nurses did not trivialize or minimize the seriousness of a patient fall, they often expressed a sense of inevitability when they talked about patient falls. They did not agree that the number of patient falls reflected their efforts to prevent them. There was a prevailing sense that some patient falls were just beyond their control. Unpredictable changes in the patient’s condition could
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contribute to falls, even with adequate supervision. Antiquated patient bathrooms and other environmental risk factors left nurses feeling responsible for falls that they could not control. One nurse described a patient who had sloughing of skin due to a drug reaction, and the many creams applied made her slippery. She slid in the bathroom and fell while the nurse was standing next to her; the patient was attempting to help herself despite instructions to the contrary. Nurses reported questioning themselves: “was there more that I could do?” But although they questioned themselves, and felt horrible after a fall, some also talked of feeling blamed. The process around postfall reviews did not feel “friendly,” and nurses were fearful of the outcome. In spite of the hospitals’ patient safety philosophies of creating a “no blame” culture, staff continued to feel that they were being held responsible for falls. This was particularly felt by staff who worked on units that were perceived to be chronically short staffed and under equipped. Nurses questioned that they have made the assessment and identified an issue but do not have the resources to implement—what is their liability? “Nurses always feel guilty when things do not go well.”
DISCUSSION This paper adds to a growing body of knowledge related to understanding experiences of nurses working in complex practice situations and, in particular, in preventing falls. It values the complex role of the nurse in real-world practice—the bricoleur, who creates practice through altering events and adjusting tools (Gobbi, 2005). Gobbi (2005) has introduced dilemmas associated with evaluating the knowledge, evidence, and practice generated by the bricoleur in determining “intellectual rigor and/or their practical application to a context for which they have not been designed” (p. 123). The concept of nurse as bricoleur in fall prevention presented in this paper does not attempt to reflect an individual’s level of expertise or evaluate the practice that was implemented. Both novice and expert nurse participants functioned in complex environments. Expert nurse bricoleurs may have integrated a deeper level of professional knowledge and clinical experience, providing a larger repertoire from which to make do, alter events, and adjust tools to create and evaluate practice. Novice nurse bricoleurs may have relied on a more limited experience, expert advice, and academic knowledge to create and evaluate practice. In the process of member checking, performed to confirm the findings of the foundational research, we introduced the concept of nurse as bricoleur to nurse participants at the three study sites. Nurses at all levels were drawn to its ability to explain their role in fall prevention, recognizing and confirming the complexity, and valuing the multitasking of everyday practice. Workload and staffing levels, local data, the stressful impact on the nurse of a fall, and the yin and yang inherent in falls prevention also were key issues in two other qualitative studies that examined the experiences of point-of-care staff in falls Worldviews on Evidence-Based Nursing, 2014; 11:2, 118–125. C 2014 Sigma Theta Tau International
Original Article prevention with similar findings (Rush et al., 2008; Stenberg & Wann-Hansson, 2011). In Rush et al.’s (2008) study with nurses, staffing was an important issue. Poor staffing prevented nurses from being vigilant in making rounds and direct contact, although adequate staffing “gave eyes and ears to high-risk patients” (p. 363). Patients calling for assistance when nurses were otherwise occupied left staff unaware of changes. Unfamiliar and cluttered environments were obstacles to falls prevention. Geographic layout was important in knowing the safety of patients. Patient characteristics contributed to the yin and yang—fiercely independent high-risk patients, patients desiring independence, led to a tension between safety and risk taking and independence. When falls did occur, it was a major stressor influenced by circumstances, extent of injury, consuming one’s day, concerns about the possibility of reprisals, lawsuits, and liability. Acceptance of patient falls “was not a giving up but an acknowledgement that often patient falls were beyond their control” (p. 364). Similar issues were identified by Stenberg and WannHannson (2011), in a study with nurses, physicians, physiotherapists, and occupational therapists. The physical environment (e.g., narrow bathrooms) and equipment, patient distance from the nurses’ station, and staff adequacy were all important issues. Personnel and frequent use of temporary employees were additional problems. Both nurses and physicians experienced a fear of reprisals and reprimands. When two recommendations were contradictory, this was experienced as an obstacle: prevent the patient from falls by using a restraint but also consider the ethical aspect and patient integrity. This dichotomy again reflects the yin and yang of falls prevention. The seemingly simple process of collaborating with patients and families to create a falls prevention plan of care based on the Falls BPG became incredibly complex in practice. Research related to patient experience of falls and their prevention confirms this complexity. In a concept analysis of partnership in the professional–patient relationship, Hook (2006) identified that the patient is recognized as “expert” in, and ultimately responsible for managing their own care, but the mechanism(s) for effectively achieving this partnership is unknown. Several qualitative studies of older persons have addressed the patient experience in relation to falls and this too is a complex phenomenon. In a study of older people’s experience of falls, Roe et al. (2008) concluded that assisting people to reflect on their falls and why they happened could help in preventing future falls, allay fear, boost confidence, and aid in rehabilitation. Yardley, Donovan-Hall, Francis, and Todd (2006) found that older persons do not reject suggestions because of ignorance about their risk of falling, but because it could threaten their autonomy and identity. From a study of older persons who had visited an emergency department after a fall, but had then opted not to employ a falls prevention strategy, Whitehead, Rundke, and Crotty (2006) recommended more focus on changing patients’ attitudes toward the intervention rather than on how the interventions should be delivered. Based on a literature review, clinical experience, and qualitative and quantitative data, Worldviews on Evidence-Based Nursing, 2014; 11:2, 118–125. C 2014 Sigma Theta Tau International
Yardley et al. (2007) promoted uptake of, and adherence to, falls prevention interventions among older people, which included public education, ensuring compatibility of interventions with a positive identity, and tailoring interventions to the individuals’ situation and values. A meta-ethnography of qualitative studies of older persons’ views on risk of falling and potential interventions confirmed this complexity (McInnes, Seers, & Tutton, 2011).
IMPLICATIONS Gobbi (2005) completed her paper with the hope that her ideas about the nurse bricoleur would provoke further debate about the realities of practice. It is our hope to contribute to that debate. As Rankin (2009) noted, it is important to pay attention to the actual, real-world work of nurses. Understanding the concept of bricoleur in the context of nursing allows us to recognize and value what nurses do in real-life practice in managing complex and dynamic patient care situations. This has implications for practice and education. At the practice level, the concept of bricolage is useful in furthering our understanding of the complexity of nursing practice. It honors that complexity and suggests that nurses justifiably modify their actions and their context, utilizing multiple sources of evidence-based knowledge. This is different from simply finding evidence and attempting to apply it; it also takes into account the different facts of the patient’s situation, the patient’s preferences, and the context of the institution in time and place. It helps us to understand the process that expert nurses use to “intuitively” decide what to do and the many facets that influence the perceptions of experience that lead to real-world clinical work. It provides a way of helping nurses to analyze and evaluate their thinking and decision-making processes so that they can better learn from themselves and communicate this thinking and action process to less experienced nurses. At the administrative level, the concept of nurse as bricoleur is useful, as it helps leaders when considering multiple aspects of a situation that need to be considered when contemplating the implementation of a change in practice. It will assist organizations to move thinking from blaming the nurse (even if not intentional) to recognizing the complexity of the environment and nurse thinking in the attempt to reduce falls. Although falls prevention appears to be a simple change in practice, this discussion has demonstrated the complexity involved. When planning to introduce a change, nurse administrators need to consider the knowledge of the nurses at the point-of-care, to assist them in analyzing what they are currently doing, and how they are considering multiple perspectives when deciding on a specific course of action. As Hamilton and Campbell (2011) identify, this would involve building on point-of-care nurses’ unique standpoint. Using the sources of evidence as a starting point in planning may facilitate change, by beginning the discussion with honoring and resourcing the complex decision-making process that the nurse will need to engage in to implement the care required.
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The Nurse as Bricoleur in Falls Prevention
At the education level, the concept of bricoleur helps us to comprehend the complexity of real-world practice. Although beginning with single, simpler concepts, it is important for faculty to recognize the complex environments into which students and new graduates will move and to assist them to recognize this complexity in the practitioners they work with in their practicums. This paper contributes to expanding our understanding of expert nursing practice. The concept of nurse bricoleur moves us to a deeper understanding of the extent of nursing knowledge—the knowing and acting together that considers multiple factors simultaneously and moves to deliberate action in a seemingly instantaneous action. By better understanding the complexity of nursing practice, we can support and improve practice and ultimately improve patient experiences and outcomes. WVN
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LINKING EVIDENCE TO ACTION • Organizational initiatives meaningfully include nurses’ point-of-care knowledge to recognize the complexities of real-world practice. • At the practice level, there is a need for: ◦ supports for nurses when falls do occur, ◦ recognition of the complexity of including the patient experience and preferences, and ◦ timely provision of local data. • At the education level, faculty can assist students to recognize this complexity in the practitioners they work with in their practicums.
Author information Helen Kirkpatrick, BPSO Co-ordinator, St. Joseph’s Healthcare Hamilton, and Assistant Clinical Professor, McMaster University School of Nursing, Hamilton, ON, Canada; Sheryl Boblin, Associate Professor, McMaster University School of Nursing, Hamilton, ON, Canada; Sandra Ireland, Assistant Clinical Professor, McMaster University School of Nursing, Hamilton, ON, Canada; Kim Robertson, Risk Management Specialist, St. Joseph’s Health Care Hamilton, Hamilton, ON, Canada. Address correspondence to Dr. Helen Kirkpatrick, St. Joseph’s Healthcare Hamilton, West 5th Campus, B324, 100 West 5th, Hamilton, ON, L8N 3K7 Canada; [email protected] Accepted 23 June 2013 C 2014, Sigma Theta Tau International Copyright
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![[Preliminary results of a community fall prevention programme: Precan study (falls prevention in La Ribera)].](/assets/img/hold.png)
