A Student-Led Demonstration
Project on Fall Prevention in a
Long-Term Care Facility
Alice Bonner, MS, APRN BC, GNP, FAANP,
Patricia MacCulloch, MS, APRN BC, ANP,
Terri Gardner, MS, APRN BC, GNP, and Chantel W. Chase, MA
Falls are a frequent and serious problem fac-ing people aged 65 and older. The incidence of falls increases with greater numbers of intrinsic and extrinsic risk factors and can be reduced by risk modification and targeted interventions. Falls account for 70% of acci-dental deaths in persons aged 75 and older. Mortality due to falls is significantly higher for older adults living in extended care facil-ities versus those living in the community. Our objective was to evaluate the effective-ness of a fall prevention training program in a long-term care setting. A single-group re-peated-measure design was used, guided by the Precede–Proceed framework. A compre-hensive review of the literature and a con-cept analysis guided the development of testing and educational materials for all nursing and ancillary facility staff. Prelimi-nary testing provided baseline data on knowledge related to fall prevention. Pre-and posttests, a fall prevention newsletter, and informational brochures were distrib-uted to nursing staff and ancillary personnel at training sessions. Certified nursing assis-tant (CNA) champions were identified and given peer leadership training. “Quick Tips” fall prevention badges were also distributed to staff. Graduate students led interdiscipli-nary environmental rounds weekly, and new falls were reviewed on a daily basis by the interdisciplinary team. A 60-day posttest evaluated retention of fall prevention knowl-edge. Fall rates at baseline and for 2 months after the intervention were compared. Pre-liminary survey data revealed fall prevention learning opportunities, with a pretest mean score of 86.78%. Qualitative data were coded and revealed specific learning gaps in intrin-sic, extrinintrin-sic, and organizational causes of falls. The 60-day posttest mean score was 90.69%; a pairedttest (tscore⫽ ⫺1.050;P⫽ .057) suggested that learning may have
taken place; however, differences in scores did not reach statistical significance. The fall rate before training was 16.1%; 30-day post-training fall rate was 12.3%, and 60-day postintervention fall rate was 9%. Based on the program results, the model was ex-panded from long-term care to the university hospital system and outpatient clinics in the same community. The collaboration be-tween a school of nursing and 1 long-term care facility led to the adoption of a signifi-cant quality improvement program that was subsequently extended to a local hospital and clinic system. Student-led projects de-signed to teach community service learning can be meaningful and can lead to changes in patient safety and quality of care. (Geriatr Nurs2007;28:312-318)
T
his student-led demonstration project on fall prevention in a long-term care facility was conducted in partnership with a 150-bed skilled nursing and rehabilitation facility in Worcester, Massachusetts. The faculty leader of the project, students, the executive director (ED), and director of nursing (DON) of the long-term care facility worked closely together in the planning and implementation of this program.Development of the Intervention
Following the students’ comprehensive lit-erature review on fall prevention in long-term care residents,1 a quality improvement
pro-gram was designed using the Precede–Pro-ceed framework.2This framework was chosen
to guide the study because it is a population-based, ecologically directed approach and could frame the health problems and characteristics such as morbidity, mortality, risk, and burden in the chosen sample.2
The precede phases assess multiple factors that shape health status and assist the planner to arrive at a highly focused subset of those
factors as targets for intervention. The precede phases also allowed us to generate specific ob-jectives and criteria for evaluation. The proceed portion of this framework provided additional steps for developing new policies and initiating the implementation and evaluation processes. The Precede–Proceed model provided our pro-gram with a continuous series of phases in the planning, implementation, and evaluation of our work.
In the next step of the implementation pro-cess, the clinical instructor and students set up a plan to meet weekly with the ED and DON of the long-term care facility to design the pro-gram. Using existing quality improvement data and recent state survey reports, the students listened to concerns from the DON and ED re-garding falls in the facility. Brainstorming gen-erated numerous ideas for the project, which were narrowed down to interventions that would have measurable outcomes and would address the facility’s needs. These included an educational program by the students for all staff, identification of unit-based falls champi-ons, weekly interdisciplinary rounds on the units, and falls data collection with feedback to the staff.
Methods
This study used a single-group repeated-measure design. All students and faculty par-ticipating in the study had completed Health Insurance Portability and Accountability Act (HIPAA) training, and those certificates were provided to the facility before the project be-gan. No charts were reviewed, and no individ-ual patients were seen by students as part of the protocol. The study was approved by the University of Massachusetts Institutional Re-view Board and the nursing facility’s corpo-rate executive committee. Staff members, in-cluding certified nursing assistants (CNAs), were recruited to participate in this study at unit meetings or in one-on-one interviews with the DON and ED. Participants were ex-posed to a single educational session on falls prevention provided by the nursing students. Testing was done and reviewed with the par-ticipants. Following the educational session for staff, champions were identified and trained to lead the fall prevention program, including providing instruction about falls prevention and appropriate interventions.
A posttest was administered to all staff imme-diately following the educational session. To optimize learning of the material, the correct answers were reviewed with the entire staff after the posttests were handed in. All partic-ipants were ensured that their answers to the pre- and posttests would be kept confidential. Staff in the housekeeping and laundry depart-ments was primarily Spanish-speaking, and those individuals were provided with tests translated into Spanish.
Sample
All staff members were considered eligible to participate in the program and were offered the learning opportunity. Of the 178 total nursing facility staff (nurses, CNAs, nonlicensed person-nel), 8 licensed nurses 8 out of 40 or 16% of the licensed staff, 40 CNAs out of 90 or 44% of the CNA staff, and 20 out of 38 or 53% of nonli-censed personnel participated in the educa-tional sessions. Altogether, we reached 40% of the total facility staff.
Intervention
The intervention process is outlined inFigure 1.
All staff were invited to attend the 40-minute fall prevention in-service, and the staff scheduler assisted in assigning a time slot or session so that appropriate coverage of patient assign-ments could be arranged. Sessions were offered twice on each shift. Staff members who at-tended on their day off were compensated by the facility. Full participation by all staff was administration’s major goal, and they worked with the students to arrange days and times for the presentations that would meet the needs of as many staff as possible. In sessions that included staff for whom the primary language was Spanish, the supervisor of the housekeep-ing department provided translation as needed. Drinks and light refreshments were provided during the presentations.
Following the educational interventions, 4 CNA champions were identified and given peer leadership training. One CNA from each nursing unit was designated a “falls champion” and was trained to enhance surveillance efforts of fall prevention interventions as well as attend weekly fall prevention meetings coordinated by the DON. The 4 CNA falls champions were
se-lected by the director based on overall job per-formance and leadership abilities.
In addition to the fall prevention education materials, the students developed a “Quick Tips” badge to be worn by all staff. This badge was a checklist of caregiver responsibilities re-lated to falls that each staff member could check before leaving a resident’s room. The Quick Tips listed on the badge were:
● Eyeglasses and hearing aids on
● Hip protectors on
● Shoes on
● Bed in lowest position
● Call light placed within reach
● Assistive device in place
● No clutter
● Floors clean and dry
Clinicians or researchers wishing to use or adapt the educational and training materials from this study may contact the author at [email protected].
Each week, students led interdisciplinary team rounds with facility staff, including the ED, DON, physical therapy, maintenance manager, housekeeping manager, charge nurses, and CNAs. During these walking rounds, the team would examine the physical safety of the envi-ronment, check functionality of assistive de-vices, and monitor employee techniques such as patient transfers, supervision of assistive devices, placement of laundry receptacles in hallways, and housekeeping and maintenance equipment use and storage.
In addition, the students attended the weekly
interdisciplinary falls meeting with facility staff. During these meetings held in the conference room, the team would discuss systems issues such as environmental safety, employee skills and training, and troubleshooting for equipment malfunction. Information from these meetings was later acted on by the facility staff members during their walk rounds in the facility.
During weekly visits to the facility, students would speak with staff on each unit, receiving feedback from employees on how the staff felt about the progress of fall prevention efforts. This feedback was used to modify further fall prevention efforts. Students offered ongoing support to staff for participating in the program.
Measures
Falls were defined and documented by nurs-ing staff usnurs-ing standard Minimum Data Set (MDS) 2.0 criteria.3This included residents who were found on the floor (unwitnessed fall), those who rolled out of bed, those who were lowered to the floor, and those who would have fallen if a staff member had not interceded. Fall rates were determined at baseline (January 2005 before the program); 30 days after the program (February 2005), and at 60 days (March 2005). Standard measure of falls per 100 residents was calculated.
Knowledge of falls prevention was obtained using a 10-item test (Appendix A) developed specifically to evaluate the staff’s knowledge Figure 1.Study Design.
and ability to perform confidently and safely in the event of a fall. Pre- and posttest questions were developed by the students based on their review of the literature and in collaboration with facility administrative and nursing staff. Consideration was given to areas of weakness that had been identified during pretesting. Nine of the items were true–false questions, and 1 item was an open-ended question to explore the staff’s knowledge and beliefs about why resi-dents fall. The nonlicensed staff (housekeepers, maintenance workers, dietary staff, and laundry personnel) were only asked to respond to 5 items that were most relevant to their work.
The posttest, plus 3 additional questions (Ap-pendix A) was used at 60 days following the original educational session to explore the re-tention of knowledge among the CNAs only. The 3 additional questions were added to assess for new knowledge that the students believed the CNAs had learned based on falls or situations that had occurred since the educational inter-vention. These 3 additional questions were not included in the statistical analysis. Given that this was a newly developed test, reliability and validity were not established.
Data Analysis
Descriptive statistics were done to describe test results. Pairedttests were used to compare differences on the 10-item pre- and posttest before and after the teaching intervention (the additional 3 questions added to the original posttest were not included). The open-ended question was analyzed using basic content anal-ysis.4 Content analysis was performed by the consultant/analyst and the students. Once cod-ing was completed by all of the investigators, the codes were discussed until consensus of categories was achieved.
Results
A total of 40 CNAs completed the pre- and posttest on the day of the educational program, and 37 CNAs (93%) completed the 60-day post-test. The participants had a mean pretest score of 86.78% and a 60-day mean posttest score of 90.69% (tscore⫽ ⫺1.050;P⫽0.57). The facility fall rate prior to training was 16.1%. At 30 days posttraining, the fall rate was 12.3%. At the 60-day postintervention in March, the fall rate was 9% (seeFigure 2).
Test results and the open-ended responses were considered and coded for specific themes. The findings revealed specific themes regarding intrinsic, extrinsic, and organizational factors for falls. Specifically, many staff members still did not correctly identify that residents should be supported on their strong side when assisting with transfers. Also staff members did not re-port that residents with an assistive device are at higher risk than those who did not require one for ambulation.
Discussion
There was no evidence of a statistically sig-nificant improvement in learning after the edu-cational sessions; however, given the improve-ment in the fall rates, it seems that new information may have been used in practice. The results here suggest that the comprehensive fall prevention program may have been success-ful in increasing the knowledge of fall preven-tion strategies among nursing facility staff. The lack of statistical significance could have been related to a ceiling effect of the pretest (pretest mean score of 86.7%). The falls rate trended down over the 3-month period following the intervention, suggesting that the comprehensive approach of the educational program, use of falls champions and support of the gerontologi-cal nurse practitioner (GNP) students may have had some lasting benefit in falls reduction.
Before the implementation of the study, we were concerned that the facility staff might not accept an educational program provided by nurse practitioner students. However, staff members seemed to embrace the idea of stu-dents’ participation and were open to attending educational seminars and listening to presenta-tions. In addition, the strong support of the ad-ministrator and DON were critical to the suc-cess and sustainability of this project. As other studies have suggested, it is essential for lead-ership and management to get behind quality improvement efforts for effective change to take place.5,6 In facilities without student
involve-ment, the integration of multiple departments in fall prevention efforts can provide the impetus to increase awareness, educate staff, and make necessary changes in guidelines or policies.
Based on issues that arose during the study, questions were added to the posttest that re-flected issues related to leaving residents alone
on the toilet, making sure eyeglasses and hear-ing aides were on, and identifyhear-ing residents with a change in condition as having a higher risk for falls. This suggests that fall prevention efforts in a long-term care facility need to be customized to meet the educational needs of staff in a spe-cific facility and that this may be an iterative process.
Sustainability of the Falls Program
The study findings were reported back to the staff and administration. In light of the positive findings, the administration revised the fall pre-vention policy to include aspects of this inter-vention. Specifically, administration felt that the inclusion of a discussion of falls during the daily morning meeting of nursing and administrative staff was critical to the falls prevention pro-gram, and this was incorporated into policy. It was believed that addressing falls at each morn-ing report allowed for all managers to be up to date on resident safety, as well as to brainstorm new interventions to prevent future falls. This project also revealed the need for falls educa-tion preveneduca-tion for all newly hired staff and an annual reeducation related to fall prevention, with job performance competencies for all per-sonnel. It became the culture of the facility that the implementation of fall prevention strategies by the interdisciplinary team became “every-body’s responsibility.”
Program Impact on Students
Following the implementation of this project, the GNP students extended their efforts on fall prevention into the adult ambulatory setting, implementing the Centers for Disease Control (CDC) and National Council on Aging Fall Pre-vention Toolkits into several clinical practice sites (www.cdc.gov/ncipc/pub-res/toolkit/toolkit. htm). The University of Massachusetts Memo-rial Family Medicine Clinic has adopted the CDC toolkit for their practice, distributing it to all of their patients aged 65 and older. In addi-tion, providers are now asking about falls at each patient visit. The University of Massachu-setts has embraced efforts to reduce both am-bulatory and inpatient falls through their qual-ity council for inpatient clinical coordinators, in efforts to begin a comprehensive fall pre-vention program throughout the hospital and clinic system.
The Massachusetts Extended Care Federation (MECF), the trade group for more than 450 pro-prietary and not-for-profit nursing homes, has used this same student program in several long-term care facilities across the state. MECF has made the fall prevention materials and quick tips badges available in an effort to assist long-term care facilities in the development of their own customized fall prevention program.
Limitations
This study had several limitations; the major limitation was the lack of a control group to compare to the intervention. Because of limited resources, we only collected data on CNAs, so it is not certain what impact the intervention might have had on nonnursing and licensed nursing staff. Learning was only assessed at baseline and 60 days; it is possible that the benefits of this 1-time program would not be sustained over longer periods of time. Future studies should consider reassessment at 1 year. The quality of the falls prevention plans and whether they were actually carried out at the resident level was not assessed; this could be done through audit processes that have been outlined in previous studies.7,8 Repeated inser-vices or follow-up sessions or focus groups might have enhanced staff learning and im-proved clinical outcomes even more. Additional qualitative methods such as in-depth interviews would be helpful in identifying barriers to im-plementation of similar falls prevention pro-grams.
Conclusion and Future Recommendations
The results from the collaboration of the Uni-versity of Massachusetts Graduate School of Nursing and a local long-term care facility high-light the mutual benefit of a partnership be-tween a school of nursing and a health care system. What began as a student-led demonstra-tion project in 1 facility culminated in adopdemonstra-tion of fall prevention programs not only at that long-term care facility but throughout a large local health care system including hospital, am-bulatory, and other long-term care facilities. In addition, a statewide health care association (MECF) has been able to encourage replication of this program at additional long-term care fa-cilities. Although the model in this feasibility study included graduate nursing students,
simi-lar models with community volunteers, family members, CNAs, and nonnursing department staff to champion falls prevention may also be successful.
References
1. MacCulloch P, Bonner A, Gardner T. Comprehensive fall prevention programs across settings: a review of the literature. Geriatr Nurs 2007;55:
2. Green LW, Kreuter MW. Health promotion planning: an educational and ecological approach. 3rd ed. Mountain View, CA: Mayfield; 1999.
3. Minimum Data Set 2.0. Baltimore, MD: Center for Medicare and Medicaid Services; 1998.
4. Lincoln YS, Guba EG. Naturalistic inquiry. Thousand Oaks, CA: Sage; 1985.
5. Taylor JA. The Vanderbilt fall prevention program for long-term care: eight years of field experience with nursing home staff. J Am Med Dir Assoc 2002;3:180-5. 6. Anderson RA, Issel LM, McDaniel RR, Jr. Nursing
homes as complex adaptive systems: relationship between management practice and resident outcomes. Nurs Res 2003;52:12-21.
7. Schnelle JF, Ouslander JG, Simmons SF. Direct observations of nursing home care quality: does care change when observed? J Am Med Dir Assoc 2006;7: 541-5.
8. Wagner LM, Clark PC, Parmelee P, et al. Use of a content analysis procedure for the development of a falls management audit tool. J Nurs Measure 2005;113: 101-13.
ALICE BONNER, MS, APRN BC, GNP, FAANP, is an in-structor at the University of Massachusetts Graduate School of Nursing Worcester, MA, and director of clinical quality at the Massachusetts Extended Care Federation in Newton Lower Falls, MA. PATRICIA A. MACCULLOCH, MS, APRN BC, ANP, is an adult nurse practitioner in the Department of Orthopedics at the University of Massachu-setts Memorial Department of Orthopedics in Worcester, MA. TERRI GARDNER, MS, APRN BC, GNP, is a graduate student at the University of Massachusetts, Worcester, MA. CHANTEL WILSON, MA, is an independent consultant. ACKNOWLEDGMENTS
The authors acknowledge the entire staff at Autumn Village Skilled Nursing and Rehabilitation Center, Worcester, Massachusetts, for their dedication to their residents and to nursing home fall prevention.
APPENDIX A Pre- and Posttest Questions
Name: ___________________ Date: ___________________.
CERTIFIED NURSING ASSISTANT POSTTEST
1. True/False Nursing Assistants have an important role in fall prevention and awareness.
2. True/False When a resident utilizes a cane or walker they’re at less risk of falling.
3. True/False When transferring a resident with a weak side, I should assist from the weak side.
4. True/False Hearing and vision loss are not associated with falls.
5. True/False Knee and hip pain are not related to falls. 6. True/False A bed or chair alarm will keep my resident
safe.
7. True/False Dizziness is a normal part of aging. 8. True/False Keeping resident rooms free from clutter is
the housekeeper’s responsibility.
9. True/False I am only responsible for those residents that are on my assignment.
10. Why do residents fall? __________________________ ________________________________________________ ________________________________________________
The following 3 questions were added to the posttest but were not included in the statistical analysis:
11. True/False It is alright to leave my resident on the toilet and go help another resident.
12. True/False When my patient seems different from usual, they could be more likely to have a fall. 13. True/False Eyeglasses and hearing aides should be on
my resident before transferring them.
0197-4572/07/$ - see front matter © 2007 Mosby, Inc. All rights reserved. doi:10.1016/j.gerinurse.2007.04.014
