Actions of the fall prevention protocol: mapping with the classification of nursing interventions

ABSTRACT Objective: to analyze the correspondence between the actions contained in the fall prevention protocol of the Ministry of Health and the Nursing Interventions Classification (NIC) by a cross-mapping. Method: this is a descriptive study carried out in four stages: protocol survey, identification of NIC interventions related to nursing diagnosis, the risk of falls, cross-mapping, and validation of the mapping from the Delphi technique. Results: there were 51 actions identified in the protocol and 42 interventions in the NIC. Two rounds of mapping evaluation were carried out by the experts. There were 47 protocol actions corresponding to 25 NIC interventions. The NIC interventions that presented the highest correspondence with protocol actions were: fall prevention, environmental-safety control, and risk identification. Regarding the classification of similarity and comprehensiveness of the 47 actions of the protocol mapped, 44.7% were considered more detailed and specific than the NIC, 29.8% less specific than the NIC and 25.5% were classified as similar in significance to the NIC. Conclusion: most of the actions contained in the protocol are more specific and detailed, however, the NIC contemplates a greater diversity of interventions and may base a review of the protocol to increase actions related to falls prevention..


Introduction
The fall is considered an event that causes the individual to end involuntarily on the ground or another low level, with or without injuries (1) . This event may be due to intrinsic factors such as physiological or pathological changes, psychological factors, and drug side effects; or extrinsic, related to the behavior and activities of individuals in the environment in which they live (2) . In the hospital environment, patients are in the process of reestablishing their health and they are considered more vulnerable.
Consequently, the falls increase the hospitalization period and the cost of treatment, besides causing physical and psychological discomforts to the patient (3) .
In the United States, it is estimated that one-third of people over 65 years old experience at least one fall a year, with recurrence in half the cases. Approximately 10% of falls result in serious injuries such as fractures, soft tissue injuries and traumatic brain injuries, which require urgent care (3) . By 2015, in the United States, about 2.8 million falls were recorded and more than 800,000 of the cases required hospitalization. The estimate of medical costs related to this incident is R$ 34 billion per year (4) .

The National Agency of Sanitary Surveillance
(ANVISA) published an incident bulletin and identified 9,423 failures in the care of different health facilities. Of them, 3,600 (38.2%) referred to the fall, is the second cause of notifications. The most common causes are a loss of balance, followed by slipping and syncope. The furniture also contributes, being the bed fall as the most reported, followed by falls in the bathroom and the chair (5) .
The likelihood of injury to health through accidents, illness, suffering or environmental factors is called risk (6) .
Patient safety understood as interventions that minimize unnecessary harm to the care to an acceptable minimum, has become a worldwide concern since unsafe practices imply risks (7) .
Through Ordinance 529, on April 1, 2013, the Ministry of Health established the National Patient Safety Program (PNSP) to collaborate in the qualification of health care.
In the PNSP, six protocols were described, including the fall prevention protocol, whose contents contemplate several actions with the intention of strengthening fall prevention strategies (8) .
Therefore, given the patient's safety context, it is known that nursing is indispensable in the implementation of safe practices, since, through preventive interventions, nurses have the skills to make decisions regarding care to adequate and harmless assistance (3,9) .
To make nursing practices more effective, nursing classification systems, useful tools to guide the nurses' clinical reasoning and establish standardized languages and, consequently, improve the care provided from the scientific base (9) . Regarding the Classification of Nursing Interventions (NIC), intervention is defined as any treatment based on the clinical judgment that the nurse performs to improve the human response to a health condition or life process experienced by a person, group or community. The NIC is comprised of 554 nursing interventions and approximately 13,000 activities, grouped into seven domains and 30 classes (10) .
However, it must be recognized that expanding the use of classification systems in clinical practice is a major challenge for nursing care. Thus, national and international studies have been developed based on the methodology of cross-mapping which allows linguistic and semantic comparison between non-standard terminologies and classification systems (11)(12)(13) . It should be emphasized that cross-mapping is the method enabling the insertion of the standardized nursing language in health institutions since it allows a consistent comparison between the practice already developed by the nurses and the content of the classification systems (14) .
Although the fall prevention protocol presents a multiprofessional approach, most of its actions are performed by the nursing team, which remains longer direct care to the patient when compared to other health professionals. In view of the diversity of actions contained in this protocol, the need arises to compare it with the standardized nursing language to investigate the applicability of the NIC regarding the patient safety, specifically to the prevention of falls. The protocol is an objective tool, easy to access and free of charge. For this reason, it is believed that the results of this research can subsidize important advances in nursing care and highlight the importance of standardized language in helping to prevent falls.
In this context, the study had as objective to analyze the correspondence between the actions contained in the protocol of falls prevention of the Ministry of Health with the NIC by means of the cross-mapping.

Method
This is a descriptive study performed by crossmapping. It is a useful tool to analyze the data contained in the nursing process, comparing existing information with the reference classifications, as NIC in this case (15) .

Data collection was carried out between May and
December 2016 and the research was carried out in Alves VC, Freitas WCJ, Ramos JS, Chagas SRG, Azevedo C, Mata LRF.
four stages. The first step included the study of the fall prevention protocol of the Ministry of Health (16) to identify and list preventive actions.
In the second stage, interventions for the prevention of falls in the NIC were selected through consultation with the NANDA-I/NIC link from the nursing diagnosis (ND) "risk of falls" (17) . All the interventions and priority suggested additional optional nursing activities to solve the problem were listed, according to their definitions. C-General and broad terms -the nursing action contained in the protocol is general and broad, that is, less specific in relation to NIC activity; D-Detailed and specific terms -the nursing action contained in the protocol is more detailed and specific when compared to NIC activity (20) .

For data analysis, Excel version 2016 was used to
calculate the concordance of the mapping through the frequency analysis. The 80% index was adopted as the minimum level of agreement in the mapping validation (21) . actions. It should be emphasized that there were actions of the protocol that corresponded with more than one NIC intervention ( Table 2).   Alves VC, Freitas WCJ, Ramos JS, Chagas SRG, Azevedo C, Mata LRF. To carry children under six months old to the responsible person (companion or nursing professional) and in a wheelchair.

D §
To carry children over six months old in stretcher or wheelchair, accompanied by the person responsible when undergoing anesthesia and sedation procedures.

D §
To schedule personal care.  To provide guidance to those responsible at the time of medication for side effects and drug interactions, this may potentiate symptoms that create a risk for falls.

B †
To guide the patient about the importance of using appropriate footwear and clothing.

C ‡
To guide patients and family members about the risk of falls and damages caused by falls.

B †
To guide patient and companion to only get up from the bed accompanied by the professional care team, even in the presence of a companion.

D §
To guide the patient and companion to ensure the use of their glasses and or hearing aid whenever they leave the bed. To advise parents that the child should always be accompanied by the caregiver when walking (in the absence of this by the nursing professional).

5665 D §
Inform the patient and/or family/responsible about the risk of falls related to the effect of a sedative and/or anesthetic.

2380 D §
To guide those responsible that if the child is in bed, remain with the raised grilles and wheels locked (pre and immediate postoperative).

D §
To guide the patient to stand up gradually (raise the head 30º, sit on the bed with feet flat on the floor for 5 minutes) before leaving the bed with the help of a caregiver. Rev. Latino-Am. Enfermagem 2017;25:e2986.

Evaluation and monitoring
To assess the risk of falls by means of a scale appropriate to the profile of the institution's patients.

D §
To assess increased risk of fracture and bleeding.

0970 1806 C ‡
To assess the independence and autonomy of walking and the need to use a patient gait device (for example walker, crutch, and cane). To periodically review medication.

C ‡
To periodically review and adjust the prescription of medications that increase the risk of falls.

C ‡
To review the occurrence of a fall to identify its possible causes.

B †
To check the use of diuretics, laxatives and/or if the patient is in the preparation of colon for exams or surgical procedure.

0430 D §
To consider in the clinical evaluation the conditions under which the patient fasts for a long period (for example, upon waking or pre and post-operative).

C ‡
To evaluate the need to use a screen protector to close the openings between them.

B †
To evaluate the risk of falls due to psychological or psychiatric factors whenever necessary.   On the other hand, a Brazilian study characterized the falls of patients in a cardiology unit, identified that 50% of them were followed up, that is, the presence of the companion did not prevent the occurrence of this adverse event (24) . Therefore, it is important to emphasize the role of the nursing team in the adoption of diversified strategies for the education of patients and family/caregivers, because to reduce the incidence of falls, they must truly understand the risk factors as well as their real responsibilities for prevention of falls. Regarding the possible contributions of the risk assessment for falls, a Japanese study described the effectiveness of a prevention program and identified a 60% reduction in the drop rate of hospitalized patients.
This multidisciplinary program was based on interventions that included assessment of the risk of falls through a standardized instrument, modifications to the environment, teaching to the patient, family/companion and team, and implementation of a prevention protocol in which patients with at least one were considered to be at high risk.
Fallout educational material was provided to patients and caregivers, including posters alongside the beds, and for patients considered unable to request assistance, movement alert devices were used (26) . In the context of these actions, identifying patients at high risk for falls is a relevant nursing assignment, so that individualized and  (30) . It should be emphasized that the three interventions that presented the highest correspondence in this study are classified as priorities in the NIC, that is, they are the most probable for the resolution of ND "risk of falls" (10) .
The intervention NIC drug control (2380) was mapped four times. It is known that some medications Rev. Latino-Am. Enfermagem 2017;25:e2986. may contribute to the occurrence of falls, especially in the elderly and hospitalized patients. The drug classes that are most associated with falls are hypoglycemic, antihypertensive, psychotropic and opioid (31) . A study whose objective was to evaluate whether patients who had fallen did use some medication, indicated that 95.4% of the patients used at least one drug associated with falls (32) . The use of drugs associated with the risk of falls reinforces the idea that all health staff, especially nursing, should take an active role in drug control in order to identify patients at high risk. Muscle weakness is a factor strongly associated with the risk of falls, especially in certain situations, such as slipping when taking a step and falling when trying to get up from the bed or chair. Muscle strengthening exercises such as stretching, increased balance, endurance, and flexibility significantly reduce the risk of falls (33) .
The pain control NIC intervention (1400) also did not correspond to the actions present in the protocol. However, pain is one of the most prevalent symptoms in people over 65 years old and can cause physical restrictions and changes in the level of consciousness, being a relevant risk factor for falls (34) . A systematic review proposed to identify an association between pain level and risk of falls in the elderly and found that pain was the most significant factor in relation to cognitive capacity, the presence of depression, visual impairment and use of sedatives (35) . These results suggest the importance of inserting actions in the protocol regarding pain monitoring and control, such as periodically assessing pain levels, ensuring pharmacological and nonpharmacological care, and reducing factors that cause pain, mainly considering the occurrence of previous falls, which aims to reduce this incident.
The NIC interventions monitoring vital signs (6680), circulatory insufficiency care (4062), circulatory insufficiency venous insufficiency (4066) and cognitive stimulation (4720) were also not mapped. The American Society of Geriatrics points out that postural hypotension is associated with the risk of falls. Supervising patients on the use of hypotensive drugs, preventing dehydration, stimulating the use of elastic stockings in patients with indication should be practical for the prevention of hypotension and, consequently, of falls (36) . Regarding cognitive stimulation, inadequate blood pressure values are associated with cognitive impairment, which increases the risk of falls threefold. Therefore, cognitive functioning may serve as an intermediate mechanism between changes in blood pressure and the risk of falls, especially in the elderly, that is, the probability of falling is highly evidenced (37) .
Another unmapped NIC intervention was sleep improvement (1850). Sleep deprivation is an influential point for the risk of falls in the elderly, as it can cause daytime sleepiness, cognitive dysfunction and reduction in reflex response time (38) . which reinforces the importance of constant vigilance of patients at high risk (40) . Educating the professionals about the factors related to the occurrence of falls is a way to demonstrate the importance of this in the control of falls, besides encouraging the understanding that the risk assessment must be linked to prevention interventions, with a view to patient safety.

The NIC intervention improved visual communication
Sharing responsibility for prevention benefits the patients, the professionals and the institution (41) . Actions such as informing the patient and the patient about their release for ambulation or not, the risk of orthostatic hypotension, anesthesia effect, and prolonged fasting are Alves VC, Freitas WCJ, Ramos JS, Chagas SRG, Azevedo C, Mata LRF. fundamental to avoid early ambulation and consequently falls, especially in the postoperative period (28) .
It is suggested that the action of the protocol "to provide immediate assistance to the patient who suffered a fall to mitigate the possible damages" did not correspond to the NIC since it does not refer to a prevention practice, but to act through the incident.  (42) .
Regarding the limitations of the study, it is suggested the possibility of not having contemplated all the actions contained in the protocol, due to its narrative structure.
Successive readings of the protocol were carried out to list all actions, and, therefore, it is believed that the methodological approach, including the validation of the mapping by experts, contributed to a greater reliability of the results.

Conclusion
The cross-mapping allowed the comparison of the Finally, it is recommended that unmapped NIC interventions be integrated into the protocol, as well as protocol actions that have not been mapped to be proposed for NICs since such interventions and actions can contribute to the prevention of falls to improve quality and safety in healthcare.