New Malay Questionnaire Gives Nurses a Validated Tool to Stop Hospital Falls

Patient falls are among the most common and most preventable safety failures in hospitals worldwide, and nurses stand on the front line of preventing them. Yet measuring whether nurses actually know what to do, believe it matters, and practice it consistently has long depended on questionnaires built for English-speaking settings. A research team at Universiti Sains Malaysia has now addressed that gap by developing and validating a Malay-language instrument called the Knowledge, Attitude, and Preventive Measure of Fall questionnaire, or KAP-PMF, designed specifically to assess nurses in Malaysian healthcare settings. The study, conducted at a teaching hospital in Kelantan and published in BMC Nursing, offers a rare example of a fully psychometrically validated fall-prevention survey for a non-English nursing workforce.

The rationale for the work is straightforward. Falls in hospital can lead to fractures, head injuries, prolonged admissions, loss of patient confidence, and substantial additional costs for health systems. Older adults and patients with certain conditions are particularly vulnerable, but any inpatient can be at risk depending on medication, mobility, and environment. Because nurses spend more continuous time with patients than any other professional group, their knowledge of risk factors, their attitudes toward prevention, and their day-to-day preventive practices are central to whether a hospital’s fall-prevention program succeeds or fails. Instruments that measure these three dimensions together, in the language nurses actually use at the bedside, are therefore a practical necessity rather than an academic luxury.

To build the questionnaire, the researchers drew on three complementary sources: a review of the published literature on fall prevention, existing validated fall-prevention instruments, and clinical guidelines for inpatient safety. From this foundation they assembled an initial pool of 33 items distributed across three domains: knowledge of falls and their prevention, attitudes toward fall-prevention practice, and self-reported preventive measures that nurses carry out in their routine work. This combination of sources is standard practice in instrument development, because it ensures that the items reflect both the scientific consensus on what prevents falls and the practical realities of nursing care, rather than the assumptions of a single author or committee.

The validation process then proceeded in carefully staged steps. Content validity was evaluated by a panel of 10 experts, who judged whether each item was relevant, clear, and representative of the domain it was intended to measure. Face validity was assessed by 30 nurses, who reviewed the draft items for readability and comprehensibility from the perspective of the people who would ultimately complete the survey. This two-layered qualitative screening is critical: an item that experts consider technically correct may still confuse respondents, and an item that reads well may still miss an important concept. Only after this refinement did the team move to the statistical phase of validation.

Construct validity, the question of whether the questionnaire actually measures the three theoretical domains it claims to measure, was tested using two complementary forms of factor analysis on independent samples of 200 registered nurses each. Exploratory Factor Analysis on the first sample allowed the underlying structure of the items to emerge from the data without imposing a predetermined model. The results supported the intended three-domain structure, with the knowledge, attitude, and preventive-measure domains explaining 48.7 percent, 61.3 percent, and 68.5 percent of their respective item variance. These percentages indicate that each cluster of items hangs together coherently around a single underlying construct, a fundamental requirement for a questionnaire that will produce interpretable domain scores.

The second sample was reserved for Confirmatory Factor Analysis, a stricter statistical test in which the researchers specify the three-domain model in advance and ask how well the observed data fit it. The final model, trimmed to 20 items, showed a satisfactory fit across all the conventional indices: a chi-square to degrees-of-freedom ratio of 1.46, a Comparative Fit Index of 0.96, a Tucker-Lewis Index of 0.95, a root mean square error of approximation of 0.07, and a standardized root mean square residual of 0.03. Values close to or above 0.95 for the fit indices, an RMSEA below 0.08, and an SRMR below 0.08 are generally regarded as evidence of good model fit, so the KAP-PMF comfortably meets accepted psychometric standards.

Reliability, the consistency with which the questionnaire measures what it measures, was assessed using three statistics. Cronbach’s alpha, the most widely cited measure of internal consistency, ranged from 0.78 to 0.86 across the three domains, above the commonly accepted threshold of 0.70. Composite Reliability, which is less sensitive to the number of items in a scale, ranged from 0.79 to 0.95. Average Variance Extracted, which quantifies how much of the variance in the items is captured by the underlying construct rather than by measurement error, ranged from 0.50 to 0.67, meeting or approaching the conventional benchmark of 0.50. Together these figures indicate that the shortened 20-item instrument retains dependable measurement properties despite the substantial reduction from the original 33 items.

That reduction itself is worth noting. The final instrument comprises just 4 knowledge items, 6 attitude items, and 10 preventive-measure items. Shorter questionnaires impose less burden on busy clinical staff, reduce respondent fatigue, and are more likely to be adopted in routine audits, training evaluations, and hospital quality-improvement programs. In resource-conscious healthcare systems, a validated 20-item tool that can be completed in a few minutes is far more practical than a sprawling survey, and the evidence that the trimmed version still fits the three-domain model and performs reliably suggests the researchers made defensible choices about which items carried the most informational weight.

The study was carried out among registered nurses at Hospital Pakar Universiti Sains Malaysia, a teaching hospital in Kelantan, and was approved by the Universiti Sains Malaysia Human Research Ethics Committee with written informed consent obtained from all respondents. It was funded by the Hospital Pakar USM Research Incentive Grant. The authors describe the evidence as preliminary, which is an appropriate caveat: the validation was conducted in a single institution, and further testing in other Malaysian hospitals, in different nursing specialties, and ideally with longitudinal designs linking questionnaire scores to actual fall rates would strengthen the case for broader use. Cross-cultural adaptation of health instruments is notoriously difficult, and a tool validated in one setting may behave differently where patient populations, staffing patterns, or fall-prevention protocols differ.

Even with those caveats, the significance of the work extends beyond one hospital in Kelantan. Malaysia’s healthcare workforce is multilingual, and much of bedside communication happens in Malay, so a validated Malay instrument removes a subtle but real source of measurement error that arises when nurses answer questions framed in a second language. The KAP-PMF also provides a template for other countries and languages where fall-prevention research has been constrained by the absence of locally validated tools. For hospital administrators, the questionnaire offers a way to identify specific gaps in knowledge or attitude that can be targeted by training, and to evaluate whether educational interventions actually shift nursing practice. For researchers, it adds a psychometrically sound instrument to a field where measurement quality often lags behind clinical ambition. As hospitals worldwide confront aging populations and rising expectations for patient safety, tools like this one, built rigorously and tested statistically, are the quiet infrastructure on which safer care depends.

Subject of Research: Development and psychometric validation of a Malay-language questionnaire assessing nurses' knowledge, attitudes, and preventive practices in hospital fall prevention

Article Title: Development and validation of a Malay questionnaire on nurses’ knowledge, attitudes, and practices in fall prevention in a teaching hospital in Kelantan: a cross-sectional study

Article References: Wahi, N., Ibrahim, M. I., Hairon, S. M., Yusoff, M., Abdullah, S. A., Zainun, R. M., & Ab Aziz, M. Z. (2026). Development and validation of a Malay questionnaire on nurses’ knowledge, attitudes, and practices in fall prevention in a teaching hospital in Kelantan: a cross-sectional study. BMC Nursing. https://doi.org/10.1186/s12912-026-05372-7

Image Credits: AI Generated

DOI: 10.1186/s12912-026-05372-7

Keywords: fall prevention, nursing, questionnaire validation, psychometrics, patient safety, Malaysia, confirmatory factor analysis, exploratory factor analysis, Cronbach's alpha, cross-cultural validation, teaching hospital, nursing research