Predictive validity of the Hendrich fall risk model II in an acute ...

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developmental study (Hendrich et al., 2003). In a following
study Kim and colleagues compared it with other two risk
assessment tools (Morse fall scale and STRATIFY) and
found that the HFRM II had a higher values of sensibility
and specificity (respectively 70% and 61.5%) than the other
two tools (Kim et al., 2007).
The risk factors included in this tool are particularly
significant for hospitalized older adults: in fact the risk of
falling is greatly influenced by acute illnesses that often
have, albeit temporary, an impact on physical and
cognitive functions, cause incontinence or require use of
drugs, such as the psychotropics (Scott et al., 2007).
The HFRM II has not been tested specifically on geriatric
population so far, but it was applied on general inpatients
population (medical–surgical, oncology, orthopedic and
gynecology units). We do not know if it can be considered a
valid and reliable tool for the fall risk assessment of elderly
inpatients and if its use can be recommended in geriatric
care units to screen elderly inpatients at risk of falling.
As widely suggested by literature, we decided to test
the predictive validity (psychometric values), reliability,
and feasibility of the HFRM II, before introducing this tool
in the routine clinical practice of a geriatric acute care unit
of an Italian Teaching Hospital. We decided not to compare
it with other existing tools as no one of those tested so far
had proved to be valid and reliable so that it can be
considered as gold standard.
2. Methods
2.1. Study design
To evaluate the psychometric properties of the tool we
used a descriptive prospective study, as it is the
quantitative methodology employed for the validation of
a tool. The study went on from June 1, 2008 to January 31,
2009.
2.2. Instruments
As the original version of HFRM II was in English, and no
official Italian version was available so far, we translated it
in Italian. We requested the authorization for the use as
well for the translation to the author, Ann Hendrich, who
also gave us detailed instructions regarding its use and
nurse training. We followed the forward–backward
translation method: the tool was translated in Italian by
two translators whose mother tongue was Italian but were
fluent in English. These two versions were then merged
into a first consensus version. The back translation from
Italian to English was made by a third person who was
fluent in English as well as in Italian, and this version was
sent to Ann Hendrich who approved the back translation.
The face validity of the Italian version was verified by a
staff nurse, a nurse researcher and a physician; consensus
on wording was achieved.
The original HFRM II, and its Italian translation, consists
of eight items: confusion/disorientation/impulsivity,
symptomatic depression, altered elimination, dizziness
or vertigo, male sex, prescribed antiepileptics, prescribed
benzodiazepines, and ‘‘get up and go’’ test, assessing the
D. Ivziku et al. / International Journal of Nursing Studies 48 (2011) 468–474
ability to stand up from a sitting position to a standing one.
Each item is assigned a specific score and the items are
weighted in different way according to different likelihood
of each of them to cause a fall. The score ranges from 0 to
16, where 16 represents the highest risk. The patient is
considered at high risk of falling if the score is 5 or higher
(Hendrich, 2007). To facilitate the compilation for the
Italian nurses, we listed the trade name of the most used
antiepileptic and benzodiazepine drugs instead of the
substance names, as in Italian hospital the trade names are
more commonly used to identify the drug prescriptions.
To register the fall during the patient hospital stay a
patient incident report form was introduced in which we
requested nurses to report information regarding all the
falls occurred in the unit (time and place of fall, fall
dynamic, consequences, days of patient hospital stay
before falling, etc.), as in the Teaching Hospital the fall
event was usually reported only if it caused physical
consequences. In this way it was possible to learn of all the
occurred fall events and relate them to the patient’s risk
scores.
2.3. Setting and population
The study was carried out at a geriatric unit of a
Teaching Hospital located in Rome. The geriatric unit had
12 beds reserved to patients over 65 years. The geriatric
patients admitted were treated for acute illnesses that had
caused the hospitalization. All the nurses employed in the
unit were qualified nurses with a bachelor degree in
Nursing. The nursing care delivery model used in the unit
was the total patient care model (Barros et al., 2007) and
each registered nurse took care daily of 6–8 patients.
All the patients aged 65 years or over, with or without
cognitive impairment, admitted to the geriatric unit during
the study period were included into the study. We
included also cognitive impairment patients because the
data could be collected easily through medical records or
patient relatives always present at the admission. We
excluded only the patients that were unconscious or
confined to bed as the full assessment with the tool could
not be completed (i.e. the get up and go test).
2.4. Data collection
All the 12 qualified nurses working in the unit were
involved in the study as each of them could assess patients
at the admission and the tool form was included in the
nursing assessment record of all geriatric patients. Specific
training of the nurses was carried out by the principal
investigator who worked as clinical nurse specialist in the
unit. The training consisted in the explanations of the
study aim, the meaning of each item and the score system,
according to the written instructions provided by the tool
author. The use of the fall incident report form that had to
be filled in after each patients’ fall was illustrated as well.
The principal investigator was present a few hours daily
in the unit during the period of the research to clarify and
discuss any doubt and collect the HFRM and the fall
incident report forms from the nursing record once they
were filled in. As the principal investigator moved in