Journal: Advanced Journal of Nursing DOI: 10.32629/ajn.v7i2.5403
Abstract
Falls are a major patient-safety concern in psychiatric inpatient settings, where conventional risk factors intersect with psychiatric symptoms, adverse effects of psychotropic medication, fluctuating cognition, and urgent toileting needs. We used an exploratory sequential mixed-methods design to develop and preliminarily validate a fall risk assessment tool for adult psychiatric inpatients. Interviews with 10 psychiatric nurses and five inpatients informed the initial item pool. The tool was then refined through two Delphi rounds involving 15 experts and weighted with a group-consensus analytic hierarchy process (AHP) matrix. Preliminary validation assessed inter-rater agreement, content validity, convergence with the Morse Fall Scale, and exploratory 1-month risk discrimination. The final tool comprised nine risk domains and 36 ordered scoring descriptors. Both Delphi rounds had 100% response rates. In round 2, absolute endorsement was high across the scoring cells (mean range, 4.53–5.00; CV range, .00–.14), although the tie-corrected 45-cell Friedman analysis showed statistically detectable but weak rank-order concordance (Kendall's W = .106, χ²(44) = 70.06, p = .007), consistent with ceiling effects and numerous tied ratings. The group AHP matrix showed acceptable consistency (CR = .024), and overall content validity was acceptable (S-CVI/Ave = .92). Among 20 inter-rater cases, ICC(2,1) was .986, risk-category agreement was 80.0%, and linearly weighted κ was .762. Among 80 convergent-validity cases, correlations with the Morse Fall Scale were strong (Pearson r = .848; Spearman ρ = .777). In the 50-patient prospective sample, the AUC was .876 (95% CI, .673–1.000). The Youden cut point was ≥12; at the exploratory clinical high-risk cut point of ≥14, sensitivity was .600 and specificity was .800. The tool demonstrated preliminary content relevance, inter-rater agreement, and convergence with the Morse Fall Scale. Its risk-discrimination performance requires confirmation in a larger multicentre external validation study.
Keywords
psychiatric nursing; inpatient falls; fall risk assessment; Delphi method; analytic hierarchy process; mixed methods; preliminary validation
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[4]Conlon, D., Raeburn, T., & Wand, T. (2024). Mental health risk assessments of patients, by nurses working in mental health settings: A qualitative study using cognitive continuum theory. Issues in Mental Health Nursing, 45(5), 488–497. https://doi.org/10.1080/01612840.2024.2320731
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[6]Hanley, J. A., & McNeil, B. J. (1982). The meaning and use of the area under a receiver operating characteristic curve. Radiology, 143(1), 29–36.
[7]Huang, H., Su, F., Huang, Q., et al. (2023). Interpretation of key points from the World Guidelines for Falls Prevention and Management for Older Adults. Military Nursing, 40(5), 113–116. [in Chinese]
[8]Janse van Rensburg, E., & van der Wath, A. (2020). Risk assessment in mental health practice: An integrative review. Issues in Mental Health Nursing, 41(11), 995–1003. https://doi.org/10.1080/01612840.2020.1756011
[9]Koo, T. K., & Li, M. Y. (2016). A guideline of selecting and reporting intraclass correlation coefficients for reliability research. Journal of Chiropractic Medicine, 15(2), 155–163.
[10]Li, Y., & Chen, W. (2018). Application status of the Delphi method in nursing management. Nursing Research, 32(21), 3339–3341. [in Chinese]
[11]Liu, S., Jiang, H., Li, K., et al. (2020). Construction of quality indicators for hematology specialty nursing. Chinese Journal of Nursing, 55(4), 574–578. [in Chinese]
[12]Nyman, M., Hofvander, B., Nilsson, T., & Wijk, H. (2022). "You should just keep your mouth shut and do as we say": Forensic psychiatric inpatients' experiences of risk assessments. Issues in Mental Health Nursing, 43(2), 137–145. https://doi.org/10.1080/01612840.2021.1956658
[13]Polit, D. F., Beck, C. T., & Owen, S. V. (2007). Is the CVI an acceptable indicator of content validity? Appraisal and recommendations. Research in Nursing & Health, 30(4), 459–467.
[14]Rao, W. W., Zong, Q. Q., Lok, G. K. I., et al. (2018). Prevalence of falls in adult and older adult psychiatric patients in China: A systematic review and comprehensive meta-analysis of observational studies. Psychiatry Research, 266, 18–25.
[15]Shen, Y. H., Hsieh, C. C., Lee, M. T., et al. (2021). Simplifying and testing the psychometric Psychiatric Patients' Fall Risk Scale: An analysis of one-year admissions. Healthcare, 9(9), 1119.
[16]Shi, Y., & Zhu, Q. (2015). Application of the Morse Fall Scale in psychiatric settings. Today Nurse, 2015(8), 116–118. [in Chinese]
[17]Siafis, S., Wu, H., Wang, D., et al. (2023). Antipsychotic dose, dopamine D2 receptor occupancy and extrapyramidal side-effects: A systematic review and dose-response meta-analysis. Molecular Psychiatry, 28(8), 3267–3277.
[18]World Health Organization. (2021, April 26). Falls. https://www.who.int/news-room/fact-sheets/detail/falls
[19]Zhang, H., Jing, L., Xu, Y., et al. (2023). Weight analysis of a comprehensive evaluation index system for hospice care services based on analytic hierarchy process. Chinese Journal of Health Policy, 16(1), 52–59. [in Chinese]
[20]Zhang, M., Xu, D., Gao, J., et al. (2022). Construction of an assessment form for protective restraint implementation in psychiatric departments based on the Delphi method. Nursing Research, 36(14), 2466–2470. [in Chinese]
Copyright © 2026 Xiuqiong Gao, Qiongxian Zhao, Huifang Li, Chengbao Zhu, Feng Guo, Wenhui Xi
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