RISK FOR FALLS IN THE PERIOPERATIVE PERIOD: CROSS-MAPPING NURSING INTERVENTION AND ACTIVITIES

Objective: to identify nursing care intended to prevent falls among perioperative patients in the literature and cross-map them with interventions/activities proposed by the Nursing Interventions Classification for the nursing diagnosis “risk for falls”. Methods: descriptive study conducted in three stages: search for nursing care reported in the literature; identification of NIC intervention; and cross-mapping based on linkage between NANDA-I/ NIC. Results: the 214 care actions identified in the literature were mapped with 84 activities distributed in 26 NIC interventions. The intervention with the highest number of correspondences with the literature was prevention of falls, which resulted in 70 mapped activities, followed by the intervention risk identification and supervision, with 35 and 19 activities, respectively. Conclusion: all the care actions identified in the literature presented correspondences to some NIC intervention/ activity. Preventing falls among perioperative patients requires ensuring environmental safety; that patients, companies and workers be educated and sensitized; the early identification of risks; in addition to continuous nursing supervision.


INTRODUCTION
Iatrogenesis, error or incident, is defined as an event or circumstance that could have resulted or actually did result in unnecessary harm to a patient, whether it originated in an intentional or non-intentional act. The occurrence of these events reflects a gap between real and ideal care delivery. 1 The Brazil's National Health Surveillance Agency (Agência Nacional de Vigilância Sanitária -ANVISA) published a report on adverse events; 272,689 incidents had been identified at a national level. Of these, 255,562 (93.7%) occurred in hospital settings and 30,448 (11.2%) involved patient falls. 2 Falls are a multifactor event defined as unintentional displacement of one's body to a lower level, with or without injuries. 3 The most common causes of falls include loss of balance, slips, and fainting and the most common sites where they occur are bed, bathrooms and chairs. 2 Surgical patients are included in the group with a potential risk for fall due to the effects of anesthetic drugs, prolonged fasting periods, and impaired mobility. 3 Injuries accruing from falls range from abrasions, bruises, fractures up to disability or death, implicating and harming the credibility of the staff and service, increasing hospital costs and the length of hospitalizations. 4 Decreasing the risk of injuries accruing from falls is based on constant assessment of risk for falls and adoption of actions that reduce or eliminate any risk identified. 5 Note that the occurrence of falls is often related to a failure of systems rather than only to professional negligence or incompetence. Hence, more important than seeking to apportion blame is to identify processes' weaknesses and adopt preventive interventions. 1 In view of this scenario, nursing plays an essential and guiding role in the prevention of this adverse event, while the Nursing Process (NP) is an ally in the implementation of preventive actions and effective interventions. Nurses should use Nursing Classification systems in the application of the NP as these systems name, organize and classify diagnoses, interventions and nursing outcomes, improving care and the credibility of the staff, while favoring patient safety. 4 Among the classification systems in nursing there is the Nursing Interventions Classification (NIC), a standardized language that comprises interventions implemented by nurses that can be used in all settings and specialties, favoring planning, documentation and communication of care. The NIC is composed of 554 Nursing interventions and approximately 13,000 activities. To facilitate its use, interventions are grouped into 30 classes and seven domains. 6 Having prior knowledge of interventions, nurses can plan care delivery, calculate the most appropriate number of workers to implement it, and understand the staff's needs regarding improvements. 7 Given the preceding discussion, this study's objective was to cross-map nursing care intended to prevent falls among perioperative patients reported in the literature with the interventions/activities proposed by the NIC for the nursing diagnosis "risk for falls".

METHOD
Descriptive study conducted in three stages using the cross-mapping method, a useful tool that encourages the development of clinical reasoning among nurses and improves nursing practice, especially in regard to the use of standardized language systems. 8 The first stage corresponded to an integrative literature review according to the following guiding question: "what are the nursing care actions reported in the literature to prevent falls among perioperative patients?" Databases included Scopus Elsevier (SCOPUS), Latin America and Caribbean Health Science Literature (LILACS), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medical Literature Analysis and Retrieval System Online (MEDLINE), and Web of Science (WOS). The controlled descriptors/MeSH used were: "accidental falls", "perioperative assistance" and "nursing". The equivalent terms in Portuguese were accessed in the LILACS database. The full texts of papers, monographs, theses, dissertations, and opinion of experts published in Portuguese, English or Spanish between 1988 and 2018, addressing nursing care to prevent falls in the perioperative period and available online free of charge, were included. The selected studies were classified into five levels of evidence. 9 Of the 118 references, 19 were excluded either because they were en la literatura de los cuidados de enfermería utilizados, encuesta de las intervenciones propuestas por el NIC y mapeo cruzado basado en el enlace NANDA-I / NIC. Resultados: las 214 experiencias de cuidados encontrados en la literatura fueron mapeados con 84 actividades distribuidas en 26 intervenciones de NIC. La intervención que más correspondió con la literatura fue prevención de caídas, que contó con 70 actividades mapeadas, seguidas de intervenciones de identificación y supervisión de riesgos, con 35 y 19 actividades, respectivamente. Conclusión: todas las experiencias de cuidados de enfermería encontrados en la literatura mostraron correspondencia con alguna intervención / actividad NIC. Para la prevención de caídas en pacientes durante el período perioperatorio es necesario que haya seguridad ambiental, conciencia educativa de los pacientes, acompañantes y profesionales, identificación temprana de riesgos y supervisión continua de Enfermería. Palabras clave: Enfermería; Accidentes por Caídas; Atención Perioperativa; Terminología Normalizada de Enfermería; Hospitalización.
Thirty-five interventions and 911 nursing activities were listed according to the Nursing Diagnosis (NDx) "risk for falls" 10 and the linkages between NANDA-I/NIC. 6 Of these, 18 (51.43%) were classified as interventions suggested to solve problems and 17 (48.57%) were additional, optional interventions, with 497 and 414 activities, respectively. Another 12 NIC interventions not connected to NANDA-I/NIC were selected because they were efficacious and pertinent to preventing falls, with 347 activities. Note that interventions and activities related to newborns or children were removed, considering that the criterion established for this study was being an adult or elderly individual. Thus, 47 interventions and 1,252 activities were selected for mapping.
The third stage involved cross-mapping using an adapted instrument 11 ( Figure 1).
Before starting cross-mapping, we noticed that 26 care actions identified in the literature had the same spelling, hence, were repeated and were excluded for this reason, so that the initial 240 nursing care were reduced to 214 that were considered good to be mapped with NIC.
Of the 47 NIC interventions listed in this study, 26 (55.32%) were mapped, so that the number of activities fell from 1,252 to 735 mappable activities. A total of 84 NIC activities were obtained after mapping and presented correspondence with the 214 care identified in the literature ( Figure 2).
The 21 (44.68%) NIC interventions not incorporated into nursing care reported in the literature are distributed into two levels of categories indicated to solve problems: suggested and optional/additional ( Figure 3).

DISCUSSION
A Nursing intervention is any treatment performed by nurses based on their clinical judgment intended to intensify patient, group or community outcomes while nursing activities are specific actions intended to implement an intervention and promote an expected result. 6 Note the literature does not make a distinction between "interventions", "prescriptions", "actions" or nursing "activities", and most are considered nursing "care", a fact that hinders the mapping process and standardization of language. unavailable or appeared more than once, while another 43 texts were excluded for not addressing the study topic. A total of 56 publications remained and after reading their full texts, a final sample of 28 studies was obtained.
The second stage included a search for NIC's nursing intervention based on the nursing diagnosis "risk for falls" 10 based the linkages between NANDA-I/NIC. 6 The interventions and Nursing activities suggested were listed, along with optional, additional suggestions, as well as interventions not linked to NANDA-I/NIC. The latter were included because they were considered pertinent and efficacious in the prevention of falls among perioperative patients.
The third stage consisted of cross-mapping care identified in the literature (first stage) and comparing it to NIC interventions (second stage). The author, and a PhD nurse with experience in the field of patient safety and crossmapping 11 , conducted this stage using an adapted instrument that presented the title and definition of the intervention at the top, the activities proposed by the NIC in a column at the left, and blank space was left in the right column to include the activities identified in the literature that were considered by experts to correspond to those proposed by the NIC.
Mapping was conducted according to the following stages and guidelines available in the literature: 12,13 a) NIC interventions selected according to the linkages between NANDA-I/NIC for the ND "risk for falls"; b) knowledge and context of ND, as well as the "meaning" of the word, is used; c) a "key word" is selected in the intervention/activity found in the literature to support the identification of interventions/activities that corresponded to NIC; d) use of verbs as key words; e) identification and description of interventions/activities that could not be mapped within the linkages between NANDA-I/NIC.

RESULTS
Most of the 28 publications that composed the sample of the integrative review are Brazilian and were published in 2014, with a cross-sectional design, a level of evidence of four, and authored by nurses.
The studies selected addressed 240 nursing care that were grouped according to similarity into 17 theme categories: 71 in control of safety environment (29.58%); 30 in education (12.5%); 23 in risk assessment (9.58%); 20 in protocols and  various activities: bed rails, nurse call buttons, keeping patients' belongings close by, non-slip floors, appropriate furniture and lighting, handrails, and adapted bathrooms. Environmental safety is important from risk assessment to the planning of preventive strategies. [15][16][17] The literature shows the importance of providing fall prevention education to workers as well as patients, families and caregivers. A total of 30 activities addressing this topic were identified. One study conducted in Rio Grande do Sul, Brazil implemented educational actions and measures intended to prevent falls over the course of five years, decreasing falls by 69.9%. 18 Educational practices include health education actions, training, encouraging the staff to provide guidance, allowing patients/families/caregivers to participate, minimizing risks and strengthening safe practices. One Portuguese hospital implemented an innovative strategy to promoting safe care, that of designating a worker to be responsible for mediating between the staff and the risk management, quality and patient safety department. These workers implement actions that are a priority for the prevention of incidents, such as actions related to safe surgeries, prevention of infection, falls and pressure One study conducted in the south of Brazil verified that 26.5% of the terms identified in nursing documentation, despite being written differently, had the same meaning, showing there is a gap between classification languages used by nurses, and therefore, a need to standardize terms in order to allow for measuring and comparing results accruing from practice, facilitating communication among workers and contributing to qualified and safe care delivery. 14 Many of the NIC activities reported in the literature as interventions/care are applicable to specific groups, which corroborates NIC orientations that only the titles and definitions of interventions need to be the same for all patients and situations, considering that activities may, and should be modified, facilitating the use of different approaches and the possibility of nurses to individualize care. 6 In regard to nursing interventions intended to prevent falls among perioperative patients identified in the literature, note that activities concerning control of safe environment were prioritized. This finding is explained by the fact that the process of preventing falls in a hospital setting, as reported by various studies, depends on establishing and maintaining a safe environment, which is obtained through the implementation of  whenever there is a change in terms of clinical condition or after a fall. 16 Supervision is defined as "purposeful and ongoing acquisition, interpretation and synthesis of data for clinical decision-making". 6 This intervention had 19 activities mapped, which focus on the monitoring and surveillance of patients and managerial actions nurses should develop with the staff, seeking safe care: improving communication and relationship between the staff and patient, reorganizing activities within the unit, increasing the number of workers, implementing active search measures in order to report events, reinforcing precautions, informing about patients at risk, and encouraging collective and active safety responsibility.
Prevention of falls and identification of risk are classified by the NIC as interventions likely to solve the NDx "risk of falls". 6 Note, however, that the intervention supervision is missing in the linkage between NANDA-I/NIC. This absence is of concern, considering that safety in the National Program for Patient Safety (Programa Nacional de Segurança do Paciente -PNSP) is directly related to periodical monitoring, seeking to assess comfort, safety and the use of medications that may increase the risk of falls. 20 Even though it does not present a linkage, this intervention should be adopted and patients should be systematically monitored to collect and interpret data, identify changes in a patient's status, and early identification of existing risk factors. By implementing this intervention, we are expanding and recognizing the role of nurses in providing safe and qualified care.
After cross-mapping nursing care presented in the literature (214) with the NIC interventions presented in this study (47), 21 (44.68%) NIC interventions lacked a correspondence with the literature: 13 (61.9%) were classified as optional, additional interventions and eight (38. 1%) are only suggested. Even though these interventions are indicated to prevent falls, they are not specific to the perioperative period, which perhaps justifies their absence in related care reported in the literature in the field. Among these, nine (42.86%) address body mechanics (positioning, transference, and exercise) and five (23.81%) address neurological processes (convulsions, delirium, dementia, cognition) and present activities that had been addressed in other NIC interventions that were mapped, such as self-care assistance: transference; positioning: wheelchair, prevention of falls; exercise therapy: muscle control, risk identification, vital signs, sedation control, and post-anesthesia care. However, due to the complexity of cross-mapping and the high number of interventions and activities brought by the NIC, we recommend that NIC interventions that were not mapped be investigated in depth by other studies for making comparisons, establishing linkages, and eliminating repetition, facilitating care practice and the correct use of standardized systems of nursing language.
ulcers. These actions focused on patient safety are the result of an effort and commitment on the part of the entire staff who are directly or indirectly responsible for care delivery. 19 In addition to providing continuing education to workers, ensuring decent working conditions and planning for the appropriate number of workers is necessary, which promotes feelings of coresponsibility among all those involved in the care process and patient safety. 3 In regard to cross-mapping the main results, the 214 care actions found in the literature were mapped with 26 interventions and 84 NIC activities. The NIC interventions that most frequently corresponded to the literature were prevention of falls, risk identification and supervision. These findings corroborate the results reported by other studies assessing hospitalized patients with a risk of fall. One of these studies reports that the interventions most frequently corresponding to the literature were prevention of falls, environmental control: safety and risk management. 16 The other study reports environmental control: safety and prevention of falls, 15 both highlighted by the NIC as the mains ones in the list of interventions suggested to solve problems.
The intervention prevention of falls is defined as "instituting special precautions with patient at risk for injury from falling". 6 Of the 60 NIC activities for this intervention, 26 were cross-mapped with 70 activities identified in the literature. Considering that the occurrence of falls is a multifactor event, activities should be very diversified, encompassing actions related to the patient, environment and workers, 15 and for this reason, some mapped activities also present correspondence with other interventions.
In regard to the intervention prevention of falls, eight activities related to the placement of accessories (e.g., bedside lamp, telephone, water, nurse call button, bedpans, and urinals) close to patients were cross-mapped, along with six activities concerning the identification of environmental characteristics that may increase the potential for falls and five activities related to the use of signs to alert the staff that the patient is at a high risk of falling -computer device, safety sticker, colored bracelets, and visual indicator on the bedroom door were some of the suggestions found.
The NIC defines the identification of risk factors intervention as: "analysis of potential risk factors, determination of health risks, and priorization of risk reduction strategies for an individual or group." A total of 35 activities were identified in the literature and mapped with three NIC activities, all addressing orientation/discussion of risk factors and planning/ implementation of activities to reduce risks. Assessment of risk for falls involving the identification of factors like history of falls, level of mobility, age, and medications and should be conducted using instruments validated for specific populations at the time a patient is admitted, every three days of hospitalization, and All nursing care presented in the literature concerning prevention of falls among perioperative patients corresponded with some NIC intervention, even if not presenting a linkage between NANDA-I/NIC. Even though standardized language is seldom used, cross-mapping used in this study shows that what nurses have been doing in their practice corresponds to what is proposed by the NIC exactly, showing the importance and possibility of applying this taxonomy in nursing care in the perioperative context. For this application to be maximized, however, nurses need to acquire knowledge concerning classification systems, developing care instrumentalized by the nursing process in light of the theoretical framework, which contributes to the implementation of interventions with more specific and directed results. 21 In addition to presenting correspondence with the NIC, these activities meet the requirements of the Ministry of Health to prevent falls in hospital settings: risk assessment, multiprofessional interventions, environmental safety, and educating patients and companions. 20 This study's limitations are related to the possibility of not having mapped care in all NIC interventions/activities available, considering the number of care identified in the literature (214) and the number of NIC (13,000) activities, as well.

CONCLUSION
Cross-mapping enabled comparing Nursing care to prevent falls among perioperative patients identified in the literature with NIC interventions and standardized activities. The 214 care actions found in the literature were mapped with 84 activities contained in 26 NIC interventions. Twenty-one NIC interventions do not correspond to any intervention/activity reported in the literature.
The NIC intervention that most frequently found correspondence to the literature was prevention of falls, which corresponded to 70 mapped activities, followed by the interventions risk identification and supervision, with 35 and 19 activities, respectively.
Preventing falls during the perioperative period requires one to pay attention to environmental safety, implement educational strategies for all those involved in the process, including patients, companions, and workers, identify risks early on, establish specific measures, and implement continuous nursing supervision.