Nurses’ Knowledge, Clinical Practices, and Structural Barriers in Hospital Fall Prevention: A Cross-Sectional Study in Albania

1. Introduction

Inpatient falls represent a critical global challenge within healthcare delivery systems, directly compromising patient physical safety, prolonging hospital stays, and escalating operational costs. While the World Health Organization (WHO) reports that an estimated 37.3 million falls occur annually worldwide—averaging 1.3 to 16.9 falls per 1,000 bed-days across clinical facilities—countries like Albania completely lack published national statistics or empirical research regarding these hospital adverse events. Standard frameworks from The Joint Commission (2024) and the Agency for Healthcare Research and Quality (AHRQ) mandate that effective mitigation relies heavily on structured nursing screening, environmental modifications, and standard side-rail protocols.

Recent clinical evidence from Dykes et al. (2020) and retrospective tertiary data confirm that customized, multifactorial nursing interventions yield far superior outcomes compared to isolated safety strategies, particularly in high-risk zones like patient rooms (71.1% of occurrences) and geriatric wards. Due to the complete absence of local baselines, the primary objective of this study is to evaluate the practical management of inpatient fall risks by analyzing front-line screening compliance, tool utilization, and specific structural barriers encountered by nursing professionals within the hospital environment.

2. Materials and Methods

2.1. Study Design

A descriptive cross-sectional study was conducted using a quantitative research approach to assess nurses’ knowledge, practices, and perceptions regarding the prevention of inpatient falls.

2.2. Study Population and Sample

The study included N = 52 active nurses working across different clinical hospital departments. Participants were selected using a non-probability purposive sampling strategy based on explicit availability, active employment status in acute or chronic care units, and a verified willingness to participate in the research.

2.3. Data Collection Instrument

Data were collected using a structured 13-item questionnaire developed and validated for the operational parameters of this study. The questionnaire included items addressing:

• Demographic and professional characteristics;
• Identification of patient-related fall-risk factors;
• Use and type of standardized fall-risk assessment scales;
• Frequency of fall-risk assessment;
• Preventive nursing practices (bedside rails and signage);
• Perceived barriers to fall prevention; and
• Qualitative suggestions for improving clinical safety.

The questionnaire included both single-response and multiple-response questions, as well as an open-ended question to capture qualitative staff feedback.

2.4. Data Collection Procedure and Ethical Considerations

The questionnaire was administered anonymously to participating nurses in full compliance with international ethical principles for scientific research involving human subjects. Participants received a detailed briefing regarding the study’s exclusively academic utilization. To guarantee absolute anonymity and confidentiality, the research instrument did not gather any direct personal or professional identifiers, ensuring that all responses were processed strictly as aggregated statistical units. Furthermore, to maintain professional ethics, the identity of the hospital has been kept anonymous. Nurses were assured of their unconditional right to withdraw from the study at any stage without facing any administrative or professional repercussions.

2.5. Data Analysis

The collected quantitative data were analyzed using descriptive statistics. Categorical variables were summarized using frequencies (n) and percentages (%). For multiple-response questions, percentages were calculated based on the total sample size (N=52) and therefore did not necessarily sum up to 100%. Qualitative responses to the open-ended question were reviewed, translated, and grouped into thematic categories according to the main issues identified by participants.

3. Results and Discussion

Part 1: Demographic and Professional Characteristics

The empirical evaluation of the study sample establishes a predominantly young and academically highly qualified nursing workforce. As outlined in Table 1, 61.5% of the surveyed personnel belong to the 20–30 age bracket. Females represent 55.8% (n=29) of the cohort, while males account for 44.2% (n=23), as shown in Table 2.

This sample baseline profile is accompanied by advanced academic achievement, as 63.5% of respondents hold a Master’s degree in nursing sciences (Table 3). Clinical representation was highest in the Surgery (32.7%) and Internal Medicine (23.1%) departments (Table 4). In terms of tenure, early-career nurses with less than 1 year and 1–5 years of clinical experience collectively account for 59.6% of the sample (Table 5).

Clinically, this highly educated but relatively inexperienced distribution creates a distinct operational challenge. As documented in the systematic review by Audet et al. (2018), a shorter clinical tenure heavily correlates with an increased risk of adverse events in acute care hospitals. This vulnerability is further magnified during the care of hospitalized geriatric patients who, as highlighted by Lauretani et al. (2019), exhibit severe physical frailty, making them exceptionally prone to devastating falls within unfamiliar ward environments.

Part 2: Assessment Protocols and Clinical Practices

The analysis of empirical data on the institutional protocol framework reveals a critical implementation gap regarding standardized safety measures. As shown in Table 6, 48.1% (n=25) of the surveyed nurses report that no structured fall risk assessment scale is used in their wards, while 15.4% (n=8) remain entirely uncertain whether such screening tools exist in their workplace.

This lack of optimization is directly mirrored in Table 7, where exactly half of the entire study sample (50.0%, n=26) states they are unaware of which specific scale is officially approved by their institution. This leaves only a small minority of the frontline staff aware of the clinical deployment of the Morse Fall Scale (MFS) at 21.1% (n=11) or the Hendrich II Fall Risk Model at 9.6% (n=5).

From a clinical standpoint, this lack of screening tool unification represents a severe vulnerability to inpatient safety infrastructure. As underscored by international guidelines, effective hospital fall prevention cannot depend on the subjective intuition of individual nurses; rather, it requires objective, continuous, and highly standardized screening protocols. When clinical tracking instruments are absent or unrecognized by frontline personnel, the institutional capacity for the early identification of high-risk individuals degrades significantly.

Despite this evident structural deficit, data compiled in Table 8 highlight a highly positive indicator regarding the individual safety culture and professional commitment of the nursing staff: the absolute majority (51.9%, n=27) declare that they perform a patient fall risk evaluation daily as part of routine monitoring.

This wide variation in screening frequency strongly supports the theoretical arguments of Wang et al. (2022) and Gliner et al. (2022), which maintain that in healthcare facilities where safety protocols are neither mandated nor regularly audited, actual nursing practices become heavily mediated by external operational pressures, such as excessive workloads or professional burnout.

Part 3: Risk Factors, Protective Measures, and Barriers

The nursing personnel demonstrated an excellent theoretical grasp of multi-factorial risk predisposing factors. As highlighted in Table 9, nurses identified the use of sedative medications (34.6%), advanced age/balance disorders (32.7%), and mental confusion (25.0%) as core contributors, with 30.8% recognizing that all these elements interact collectively.

Regarding localized safety intervention rates, frontlines actively implement routine side-rail protocols, with 48.1% “Always” and 30.8% “Often” securing beds (Table 10). Visual safety alert signaling was used “Always” by 59.6% of the staff (Table 11).

However, the actual translation of this high individual awareness into consistent clinical safety measures is severely restricted by systemic bottlenecks. As detailed in Table 12, frontline nurses explicitly identified a high workload (42.3%) and acute nursing staff shortages (40.4%) as the primary barriers undermining preventative efforts.

These findings align perfectly with King et al. (2018), demonstrating that severe time compression and inadequate human resources place massive pressure on nursing teams, directly degrading their capacity to maintain routine safety protocols. Consequently, structural workforce optimization is an absolute prerequisite to achieving genuine clinical safety.

Part 4: Qualitative Summary of Open-Ended Responses

To capture direct staff perspectives, qualitative comments from the open-ended item were categorized into clear thematic dimensions. The translated feedback matches the quantitative barriers closely, highlighting severe shortages and calling for specialized infrastructure.

Suggestion Category	Direct Feedback and Comments Provided by the Nursing Staff
Human Resources Management	• Increasing staffing numbers and routine staff training. • Providing additional staff to handle patients with severe balance issues or acute impairments.
Logistics and Infrastructure	• Procuring necessary equipment, but above all, an increase in qualified bedside staff. • Introducing newer, modern equipment and improving necessary safety tools.
Clinical Standardization	• Mandatory protocols for new nurses and continuous targeted nursing education. • Dividing daily shift tasks equitably so everyone is ready to reduce the risk of patient falls.
Patient Cooperation & General	• Improving close cooperation with the patient and acquiring proper safety equipment. • I would not improve anything specific in my unit.

4. Discussion

This study provides an important overview and an initial empirical baseline regarding the knowledge, clinical practices, and structural barriers faced by nurses in managing patient fall risks within hospital environments in Albania. The analysis of the demographic profile reveals a predominantly young workforce (61.5% aged 20–30 years old) with a high level of academic qualification, as 63.5% of them hold either a Scientific or Professional Master’s degree. However, this advanced theoretical preparation is accompanied by a relatively short clinical tenure, with nearly 59.6% of the nurses having less than 5 years of work experience. This imbalance between higher education and limited experience creates a unique operational challenge. According to a systematic review by Audet et al. (2018), a shorter clinical tenure in acute care settings significantly correlates with an increased risk of adverse hospital events. This vulnerability is further magnified when caring for geriatric patients (who accounted for 5.7% of the cases in this study), individuals who, as highlighted by Lauretani et al. (2019), exhibit severe physical frailty and gait/balance disorders that make them exceptionally prone to devastating falls within unfamiliar ward environments.

The most critical finding of this research relates to the major institutional gap in implementing standardized assessment protocols. The data demonstrate that 48.1% of the nurses report that no structured fall risk assessment scale is utilized in their respective wards, and a striking 50.0% of the sample stated they are completely unaware of which specific scale is officially approved by their institution. Only a small minority recognized internationally validated instruments, such as the Morse Fall Scale (MFS) (21.1%) or the Hendrich II Fall Risk Model (9.6%). This lack of standardization directly contradicts the standard guidelines established by The Joint Commission (2024) and the Agency for Healthcare Research and Quality (AHRQ, 2023), which specify that effective fall prevention cannot depend on the subjective intuition of frontline staff; rather, it requires objective and continuous screening. When clinical tracking instruments are either missing or unrecognized by frontline personnel, the institutional capacity for the early identification of high-risk patients degrades drastically.

Despite this structural deficit, the study revealed a robust individual safety culture and professional commitment among the nursing staff. The absolute majority (51.9%) declared that they perform a patient fall risk evaluation daily as part of routine monitoring, while 48.1% “Always” secure bedside rails, and 59.6% utilize visual fall risk signage. This discrepancy between the individual willingness of the staff and the absence of official institutional protocols supports the theoretical arguments of Wang et al. (2022) and Gliner et al. (2022). These authors verify that in healthcare facilities where safety protocols are neither mandated nor regularly audited, actual nursing practices remain fragmented and are heavily mediated by external operational pressures, such as hourly rounding dynamics or communication within the care team.

Furthermore, this study documents that the high theoretical grasp of fall-related risk factors among nurses (identifying sedative medication use at 34.6%, advanced age/balance disorders at 32.7%, and mental confusion at 25.0%) is directly undermined by systemic bottlenecks within the hospitals. Frontline nurses explicitly identified high workloads (42.3%) and acute staffing shortages (40.4%) as the primary barriers sabotaging their preventative efforts. These findings align perfectly with the study by King et al. (2018), which demonstrates that severe time compression and inadequate human resources place massive pressure on nursing teams, ultimately degrading their capacity to maintain routine safety interventions, such as frequent monitoring or physical assistance during mobilization.

From an economic and managerial standpoint, as suggested by Spetz et al. (2015), investing in the optimization of nurse-to-patient ratios and procuring appropriate safety equipment (such as functional low-beds, sensors, etc.) yields a high return on investment (ROI). This occurs because it drastically reduces the extraordinary healthcare costs associated with prolonged lengths of hospital stay and the treatment of secondary injuries resulting from falls. The qualitative feedback gathered from the open-ended item in this study strongly reinforces these dimensions, as frontline staff urgently call for an expansion of human resources, continuous education on new protocols, and upgrades to the logistial infrastructure.

Limitations of the Study:This study presents several limitations that must be taken into consideration. First, the sample size (N = 52) is relatively small and concentrated within a specific university/hospital context, which limits the generalizability of the findings on a national scale. Second, the cross-sectional design and the utilization of self-reported questionnaires may introduce social desirability bias, where nurses might report a higher compliance rate with preventative measures (such as side rails or signage usage) than what actually occurs in daily practice. Nonetheless, as this represents one of the baseline empirical investigations of its kind in Albania, it serves as a critical wake-up call for hospital managers and healthcare policymakers.

5. Conclusions

Inpatient falls remain a critical challenge within modern healthcare delivery systems. This study highlights that while hospital nurses possess strong theoretical knowledge and safety vigilance, their clinical efficacy is heavily compromised by an absence of standardized screening scale tools and major structural workforce constraints, such as high workloads and staffing shortages. To bridge this clinical implementation gap and cultivate a resilient safety culture, hospital administrations must transition from subjective approaches to unified screening mechanisms by embedding mandatory protocols like the Morse Fall Scale across all acute units. Furthermore, strategic institutional investments aimed at optimizing staffing ratios and upgrading clinical equipment are vital prerequisites to guarantee patient safety and elevate the quality of clinical care.

6. Recommendations

Based on the empirical findings and systemic barriers identified in this study, the following multi-level strategic recommendations are proposed to enhance inpatient safety and bridge the gap between nursing knowledge and clinical practice:

1.

Institutional Standardization and Protocol Integration

Mandate Unified Risk Assessment Toolkits: Healthcare facilities must transition away from subjective nurse intuition by embedding validated assessment scales, such as the Morse Fall Scale (MFS) or the Hendrich II Fall Risk Model, as mandatory electronic or paper-based admission and shift-change requirements.

Establish Clear Clinical Pathways: Develop standardized post-fall protocols and clear institutional guidelines that dictate exact nursing actions based on the patient’s calculated risk score (e.g., high-risk signage, targeted surveillance).

2.

Workforce Optimization and Structural Reforms

Enhance Nurse-to-Patient Ratios: Hospital administrations must strategically address staffing shortages (reported by 40.4% of participants) to reduce clinical time compression, allowing frontline nurses to maintain routine safety checks and hourly rounding.

Equitable Shift Workload Management: Implement real-time workload balancing tools to ensure that acute care units experiencing high bed-turnover or treating highly vulnerable geriatric patients are supported by adequate auxiliary nursing personnel.

3.

Continuous Professional Development (CPD)

Institutionalized Training Programs: Design and execute mandatory onboarding programs for newly hired nursing personnel, focusing heavily on hands-on risk screening, environmental modification techniques, and the correct application of bedside safety measures.

Routine Safety Audits and Feedback: Conduct regular clinical audits to track protocol compliance and organize periodic feedback sessions to address evolving practical bottlenecks encountered by the frontline staff.

4.

Environmental and Infrastructure Upgrades

Procure Specialized Safety Equipment: Direct strategic financial investments toward modernizing ward infrastructure, specifically focusing on low-height electronic beds, non-slip flooring materials, robust bedside grab-bars, and wireless patient-bed motion sensors.

Standardize Visual Alert Signaling: Universalize the deployment of highly visible bedside and wristband fall-risk signage to instantly alert the entire multidisciplinary healthcare team of a patient’s vulnerability