Unassisted Toileting Falls on a 28-Bed Medical-Surgical Unit: Appraising the Evidence Behind Purposeful Rounding Before Changing Practice
[Author Name]
School of Nursing, Purdue University Global
NU325 Evidence-Based Nursing
Unit 4 Assignment
[Faculty Name]
August 11, 2026
Original model document. The unit, its fall data and its staff are composites; no employer, patient or coworker is described.
The Practice Problem as It Appears on the Unit
The problem I want to work on is one I can describe before I can count it. On the composite 28-bed adult medical-surgical unit in this paper, staffed at one nurse to five patients on days and one to six at night, the falls that reach an incident report almost never happen while anyone is in the room. A patient who was oriented at 2200 tries to reach the bathroom alone at 0300, does not use the call light, and is found on the floor beside the bed with the side rail down and the urinal still on the tray table. Nurses on the unit describe that same picture to each other after nearly every event.
Counting the problem changed how it looked. Over six months the unit recorded 14 patient falls across 4,180 patient days, a rate of 3.3 falls per 1,000 patient days, which sits inside the range commonly reported for medical-surgical units rather than above it (LeLaurin & Shorr, 2019). Three of the 14 caused injury: two skin tears with hematoma and one hip fracture in an 81-year-old admitted for pneumonia. Nine of the 14 involved a patient moving toward the bathroom without help. Eight happened between 2300 and 0600. Eleven of the 14 patients carried a Morse Fall Scale score of 45 or higher, documented on the shift the fall occurred.
Two things follow from those numbers. The first is that our screening tool is not failing to identify who is at risk; it flagged 11 of the 14 before they fell, which means the gap is between knowing and acting. The second is that the falls cluster in one window and one activity, so a change aimed evenly at the whole shift spends most of its effort where the falls are not. Injury also carries a payment consequence, since a fall with injury is among the hospital-acquired conditions for which Medicare does not pay the added cost of care (Centers for Medicare & Medicaid Services, 2024). The Joint Commission (2015) reports that a fall with injury adds roughly 6.3 days and about $14,000 to a stay.
Why What I Have Seen Is Not Enough
Everyone on the unit already has an explanation, and mine was purposeful rounding. I have worked nights where we checked every patient on a set schedule and nobody fell, and I remember those shifts clearly. What I do not remember with the same clarity are the nights we rounded on schedule and someone fell anyway, because those events get written up and then absorbed into a bad shift. Experience collects the cases that confirm a belief and quietly loses the ones that do not, and a unit with 14 falls in six months does not have enough events for any nurse to see a pattern honestly.
That is the reason to look outside the unit. The Johns Hopkins model treats personal experience as evidence, but as the weakest kind, and asks the nurse to set it beside research and say plainly which is stronger (Dang et al., 2022). Applying that here means my rounding story enters this paper as a hypothesis rather than as a finding, and the question becomes answerable: for adults on a medical-surgical unit, does a structured rounding schedule reduce falls compared with usual care? Asking it that way also fixes what I have to look for, which is studies that counted falls, not studies that measured whether patients felt attended to.
Where I Looked and What the Evidence Supports
I searched CINAHL and PubMed through the university library, then went straight to the Agency for Healthcare Research and Quality and the Cochrane Library, where synthesized evidence and practical tools sit. My terms were fall or falls combined with hospital or inpatient or 'medical-surgical', and with rounding or 'hourly rounding' or 'fall prevention'. I limited results to English, adults, and 2013 forward, and kept only sources that reported falls per 1,000 patient days rather than satisfaction scores or rounding compliance. That returned more than 200 records. I read 18 abstracts, retrieved nine papers, and kept four that speak directly to the practice question.
The strongest evidence was less encouraging than I expected. The Cochrane review of falls prevention in care facilities and hospitals found that multifactorial programs may reduce falls in some hospital settings, rated the certainty of that evidence low, and did not support single interventions used on their own (Cameron et al., 2018). A review of the state of the science in acute care arrives at the same place from another direction: several practices that feel effective at the bedside, bed alarms most famously, have not reduced falls when tested, and the evidence behind structured rounding is inconsistent (LeLaurin & Shorr, 2019). My hypothesis survived as a component and failed as a whole answer.
What does have support is narrower and more specific than a schedule. The Agency for Healthcare Research and Quality (2013) toolkit builds fall prevention from universal precautions for every patient plus interventions matched to the individual risk factors a screening tool identifies, with the care plan naming the actual risk rather than the score. That maps onto this unit's own data, where falls concentrated in unassisted toileting between 2300 and 0600 among patients already flagged as high risk. The Joint Commission (2015) points the same way, treating fall prevention as a program with leadership support and staff education behind it rather than as a single practice one night shift adopts.
What I Would Change, and What I Cannot Change Alone
The change I would take to the unit practice council is narrower than the one I started with. For every patient whose screening score is 45 or higher, a scheduled toileting round at 2300, 0200 and 0500, offered rather than announced, with the patient walked to the bathroom rather than handed a urinal, and the call light, the bed alarm setting and the path to the bathroom checked at each round. Rounding continues on the existing schedule for everyone else. The point of narrowing it is that a unit can actually do three rounds for eight patients at night and cannot reliably do them for 28.
I would want three numbers before and after. The outcome measure is falls per 1,000 patient days, which the unit already reports monthly, compared across the six months before and the six months after, with falls during unassisted toileting counted separately because that is what the change targets. The process measure is documented completion of the three night rounds for high-risk patients, audited on 10 patients a month. The balancing measure is night shift overtime, since a change that quietly depends on unpaid time is not sustainable and disappears when the nurses who championed it move on.
There is a boundary around what a staff nurse can do with this, and stating it belongs in the paper rather than in an apology. I can bring the data, the four sources and a written proposal to the practice council, and I can change my own practice tonight. I cannot change the screening tool, the staffing ratio, or the door width in rooms where a walker does not fit, and nothing I found supports asking for those. I also cannot claim this change will prevent falls. Certainty in this literature is low, the unit's rate already sits inside the usual range, and six months of data on one unit shows a direction rather than a result.
References
Agency for Healthcare Research and Quality. (2013). Preventing falls in hospitals: A toolkit for improving quality of care. U.S. Department of Health and Human Services. https://www.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/
Cameron, I. D., Dyer, S. M., Panagoda, C. E., Murray, G. R., Hill, K. D., Cumming, R. G., & Kerse, N. (2018). Interventions for preventing falls in older people in care facilities and hospitals. Cochrane Database of Systematic Reviews, 2018(9). Cochrane Library. https://www.cochranelibrary.com
Centers for Medicare & Medicaid Services. (2024). Hospital-acquired conditions. U.S. Department of Health and Human Services. https://www.cms.gov
Dang, D., Dearholt, S. L., Bissett, K., Ascenzi, J., & Whalen, M. (2022). Johns Hopkins evidence-based practice for nurses and healthcare professionals: Model and guidelines (4th ed.). Sigma Theta Tau International.
LeLaurin, J. H., & Shorr, R. I. (2019). Preventing falls in hospitalized patients: State of the science. Clinics in Geriatric Medicine, 35(2), 273-283.
The Joint Commission. (2015). Preventing falls and fall-related injuries in health care facilities (Sentinel Event Alert No. 55). https://www.jointcommission.org
How this NU 325 Unit 4 example is structured
In many sections this unit asks a nurse to take a practice problem to the evidence and judge whether the evidence supports the change; your classroom's instructions and the rubric posted with the assignment decide the exact form. This NU325 Unit 4 example is written in the order the thinking happened. The first sheet describes the problem as it appears on the unit and then counts it. The second says why what a nurse has already seen is not enough on its own, which is the step most papers skip. The third reports where the search went and what the sources support, including the finding that contradicted the writer's expectation. The last separates what a staff nurse can change from what needs the practice council. The unit is a composite.
NU325 Unit 4 questions, answered
What does NU325 Unit 4 usually ask for?
In many sections this unit asks you to name a practice problem, search for evidence about a possible change, judge how good that evidence is, and say what you would do. The exact form belongs to your classroom, so read the assignment instructions and the rubric in the unit, since required sections and the number of sources vary by section and term.
Do I have to use a practice problem from my own job?
Write about a problem you recognize, but build the unit as a composite. Never name an employer, a manager, a coworker or a patient, and do not use real incident data you can access at work. Composite numbers that are realistic serve the paper just as well and keep you clear of privacy policy and your employer's rules about sharing internal data.
How is this different from an appraisal in a graduate course?
A graduate paper appraises at a higher bar: a formal search strategy, sources labeled by level of evidence, and a judgment about certainty. This paper starts where a nurse already stands, with something seen at the bedside, and its main work is reaching past that experience to evidence. Both end with a practice decision, but the graduate version has to defend its method too.
Write yours, or have the desk draft it
This paper is an original model document written by our desk, not a submitted student paper and not an official Purdue University Global document. Read it for the moves, then write your own to the instructions in your classroom. If you want one built to your exact prompt and rubric, the first custom sample is free and arrives in 24 to 48 hours.