FALL PREVENTION SERVICES FOR OLDER ADULT, AMERICAN
FALL PREVENTION SERVICES FOR OLDER ADULT, AMERICAN
INDIANS/ALASKA NATIVES: AN EXAMINATION OF KNOWLEDGE,
ATTITUDES, AND PRACTICES OF HEALTH CARE PROVIDERS
By
SUSAN ELIZABETH DUCORE
Submitted in partial fulfillment of the requirements for the degree of
Doctor of Nursing Practice
Committee Chair: Dr. Deborah Lindell
Frances Payne Bolton School of Nursing
CASE WESTERN RESERVE UNIVERSITY
May, 2018
FALL PREVENTION SERVICES FOR OLDER ADULT, AMERICAN 2
CASE WESTERN RESERVE UNIVERSITY
FRANCES PAYNE BOLTON SCHOOL OF NURSING
We hereby approve the scholarly written project of
Susan Elizabeth Ducore
Committee Chair
Dr. Deborah Lindell
Committee Member
Dr. Carol Musil
Committee Member
Dr. Bruce Finke
Date of Defense
April 20, 2018
*We also certify that written approval has been obtained for any proprietary material contained therein
FALL PREVENTION SERVICES FOR OLDER ADULT, AMERICAN 3
Abstract
Background and Purpose: Falls and fall-related injuries are an ongoing public health concern since one in three adults over 65 years of age is expected to fall each year and, of those who fall, an estimated 33 % will require a medical intervention.
Despite the evidence that most older-adult falls are preventable and that evidence- based clinical practice guidelines for identifying and managing risk are widely available, often a gap between scientific evidence and clinical practice exists. This study examined, within the context of Indian healthcare organizations, health care providers’ knowledge of, attitudes toward, and practice (KAP) of evidence-based, older adult fall prevention and the potential relationships among these concepts. The
Promoting Action on Research in Health Services framework was selected to guide the study and interpretation of findings since knowledge, attitude, and behavior may influence fall prevention practice and are, for the purpose of this study, considered sub-factors in terms of the framework. Methods: A self-administered, Likert-type, questionnaire was distributed on-line to 222 health care providers (HCPs). It was completed by 33 health care professionals, employees of one or more of the approximately 41 federally-funded tribal healthcare organizations located within the
California Area Indian Health Service. Results: Fewer than half of the health care providers (33 %) indicated “very knowledgeable” about older adult fall prevention.
Most (97 %) acknowledged that preventing falls in older adults is “urgent’ or
“somewhat urgent”. A majority of health care providers perceived older adult fall prevention as “very important”, responses at 85 % and above. However, practice-
FALL PREVENTION SERVICES FOR OLDER ADULT, AMERICAN 4
wise, as to the six older adult fall prevention services, most indicated their organizations provided them only “sometimes or for some patients” or by “referral to
other person or organization”. No statistically significant relationships were found
between aggregate survey subscale items identified with knowledge, attitude and
practice variables. The analysis did indicate statistically significant relationships
between various HCP knowledge and attitude associated survey items. Discussion:
Study findings indicate that HCPs’ attitude (perception) is consistent with scientific
evidence-based, older adult fall prevention, however that gaps, in terms of HCPs’
knowledge and organizational practice, exist. These findings have implications for
enhancing the effectiveness of older adult fall prevention services offered by
American Indian/Alaska Native (AI/AN)-serving healthcare organizations, for
inspiring future research geared toward examining older adult AI/AN knowledge,
attitudes and practices associated with fall prevention, and ultimately for improving
health outcomes for older adult AI/ANs.
Keywords: knowledge, attitudes, practice, community-dwelling AI/AN,
American Indian/Alaska Native, older adult fall prevention, fall risk reduction,
evidence-based clinical practice guidelines, community-based fall prevention, health
care provider
FALL PREVENTION SERVICES FOR OLDER ADULT, AMERICAN 5
Copyright
Copyright (2018) by Susan Elizabeth (Conn) Ducore, B.S.N., B.A. Sociology, M.S.N., PHN
FALL PREVENTION SERVICES FOR OLDER ADULT, AMERICAN 6
Acknowledgements
First and foremost, to my dear husband Jonathan and our family, “thank you” for inspiring, supporting, and encouraging me to pursue my dream of attaining a
Doctorate in Nursing. I could not have achieved this personal and professional goal without your love and dedicated support!
Special gratitude to my academic advisor and doctoral committee chair, Dr.
Deborah Lindell, and committee members Dr. Carol Musil and Dr. Bruce Finke for generously sharing your time, insight, knowledge and expertise. My work is better because of your guidance and dedication to the profession and to academic excellence!
To the excellent and highly dedicated dean, faculty and staff of the Case
Western Reserve University, Frances Payne Bolton School of Nursing, “thank you” for ensuring the opportunity for academic and professional growth through a rigorous
DNP program!
To the California Area Indian Health Service Executive Leadership, “thank you” for acknowledging the importance of this scholarly project through your “letter of support”.
And finally, to the highly dedicated and talented health care professionals who volunteered their time and expertise to participate in the study, “thank you” for your commitment to improving health and quality of life outcomes for American
Indians/Alaska Natives living in California!
FALL PREVENTION SERVICES FOR OLDER ADULT, AMERICAN 7
Table of Contents
Section I.
Title Page..………………………………………………………………………….…1
Committee Approval Page...……………………………………………………...... 2
Abstract ...... 3
Copyright……..……………………………………………………………………….4
Section II. Introduction
Chapter I...…….…………………………………………………………………….10
Background ...... 11
Problem ...... 17
Purpose ...... 17
Research Questions ...... 17
Conceptual Framework ...... 18
Definitions ...... 20
Assumptions ...... 26
Significance for Nursing ...... 26
Summary ...... 28
Section III. Review of Literature
Chapter II…………………………………………………………………...……....30
Review of Literature ...... 30
Purpose ...... 30
Literature Review Process ...... 30
Phenomena of Interest ...... 31
FALL PREVENTION SERVICES FOR OLDER ADULT, AMERICAN 8
Older Adult Falls as a Public Health Concern ...... 32
Fall Risk and Chronic Disease ...... 33
Aging, Chronic Disease, and Fall Risk ...... 34
Fall Risk and Practice ...... 37
Approaches for Fall Risk Identification, Assessment and Management ...... 40
Clinical Practice and Fall Prevention Practice Guidelines ...... 41
Summary ...... 57
Section IV. Methods
Chapter III..………..……………….…………………………………………….....60
Methods ...... 60
Purpose ...... 60
Setting...... 60
Population...... 61
Sample ...... 61
Definitions of Variables ...... 62
Table I ...... 63
Measurement ...... 66
Demographics...... 66
Procedure ...... 67
Protection of Human Subjects...... 67
Recruitment...... 68
Data Management ...... 69
Data Analysis ...... 70
Section V. Results
FALL PREVENTION SERVICES FOR OLDER ADULT, AMERICAN 9
Chapter IV ...... 75
Results ...... 75
Table II ...... 76
Table III ...... 79
Table IV ...... 81
Table V ...... 84
Table VI…….…………………………………………………………………..….86
Table VII ...... 89
Table VIII ...... 91
Table IX ...... 96
Table X ...... 97
Section VI. Discussion
Chapter V...……………………………………………………...………………….98
Discussion...... 98
Section VII. References
References……………………………………………………………...…………..120
Section VIII. Appendices
Appendix A ...... 139
Appendix B ...... 140
Appendix C ...... 141
Appendix D...……………………………………………………………………….146
Appendix E..………………………………………………………………………..147
Appendix F..………………………………………………………………………..149
FALL PREVENTION SERVICES FOR OLDER ADULT, AMERICAN 10
Chapter 1
Falls in older adults are common and of major public health concern both in
the U.S. and internationally. They often lead to serious injury resulting in economic burden, reduced quality of life, extended periods of hospitalization and in severe cases, increased mortality (Child, S., Goodwin, V., Garside, R., Jones-Hughes, T.,
Boddy, K., & Stein, K., 2012; Rubenstein & Josephson, 2006; World Health
Organization [WHO], 2007). According to Rubenstein (2006), older adult falls account for 40% of all injury deaths in the U.S. Based on more recent estimates, of the 10 leading causes of nonfatal injuries treated in hospital emergency departments in the United States, unintentional falls are the leading cause of nonfatal injuries in persons 65 years of age (CDC National Center for Injury Prevention and Control,
2013). In terms of the population of interest for the current research, the expanding population of American Indian/Alaska Native (AI/AN) community-dwelling older adults, risk for elevated unintentional injury and chronic disease burden is well documented, with data to suggest that chronic disease, injuries, and behavioral problems are leading causes of death and premature mortality (Rhoades & Rhoades,
2014).
Several effective fall prevention (FP) interventions, those based on widely available evidence-based standards and clinical practice guidelines, and supported by empirical studies, have been identified (American Geriatrics Society/British
Geriatrics Society, 2010; Noonan, Sheet, & Stevens, 2011; Registered Nurses’
Association of Ontario, 2005). Such resources offer healthcare providers a structure
FALL PREVENTION SERVICES FOR OLDER ADULT, AMERICAN 11
for integrating evidence into the practice of older adult fall prevention through community-based healthcare settings (American Geriatrics Society/British Geriatrics
Society, 2010; Registered Nurses’ Association of Ontario, 2002). However, there is ongoing concern that evidence-based, older adult fall prevention practice recommendations are not being implemented across clinical and community health care settings at the pace needed to effectively reduce fall risk and associated injury
(Noonan et al., 2011; Tinetti, Gordon, Sogolow, Lapin, & Bradley, 2006). Child et al. (2012), while attempting to explain the complexities and multifactorial nature of fall-prevention intervention, identify the following concepts as important: practical considerations, adapting for community, and psychosocial.
Background
Approximately one in three adults over the age of 65 years suffer from a fall
event each year; 20% -30% of these events result in a serious injury that requires
medical intervention (Alexander, Rivera, & Wolf, 1992; World Health Organization
(WHO) website, 2012). The number of persons living past the age of 65 years, in
both the general population and the AI/AN population subset, is expanding.
Population growth trends project increased growth in size of the overall US
population by 31% and that of the AI/AN subset by 41.7 % between years 2014 and
2060 (Colby & Ortman, 2014).
Chronic health conditions such as cardiovascular disease, diabetes, and
neurological disorders are often associated with the aging process and with elevated
fall risk. Chronic diseases disproportionately affect older adults and are known to
FALL PREVENTION SERVICES FOR OLDER ADULT, AMERICAN 12
contribute to disability, lowered quality of life, and elevated care-related costs (Burns,
Stevens, & Lee, 2016). Based on 2010 data, reportedly three in four Americans aged
65 years and older have two or more chronic health conditions, those that last a year
or more and require ongoing medical intervention (Gerteis et al., 2014). A 2015
Agency for Healthcare Research and Quality (AHRQ) report suggests that more than
25% of all Americans are estimated to have at least two chronic physical or
behavioral health problems ("Multiple Chronic Conditions," 2015). This same report
suggests that the cost of treatment for people living with these multiple chronic
conditions (MCC) currently accounts for an estimated 66 percent of the Nation's health care costs. A Centers for Medicare and Medicaid (CMS) report, based on 2010
data, suggests that among a study population of Medicare beneficiaries, more than
two-thirds or 21.4 million beneficiaries had two or more chronic conditions (Centers
for Medicare and Medicaid Services [CMS], 2012). These data demonstrate that a
large number of older adults in the U.S. population are living with one or more
chronic conditions, a trend predicted to continue as the segment of the U.S.
population ages. Such trends are cause for major public health and individual concern in terms of suboptimal health outcomes, diminished quality of life, and rising
health care costs.
Unintentional falls are often associated with risk factors such as abnormalities
of balance and gait, cognitive impairment, sedative use, and foot problems, all of
which may be associated with chronic health conditions as well as the normal aging
FALL PREVENTION SERVICES FOR OLDER ADULT, AMERICAN 13
process. For older persons living in the community, as the number of fall-risk factors present increases, so does the risk of falling (Tinetti, Speechley, & Ginter, 1988).
The research literature clearly suggests that many older adult falls in community-dwelling individuals can be prevented through use of a multifactorial, multidisciplinary approach for assessing fall risk followed by a tailored intervention
(Centers for Disease Control and Prevention, 2015; Fortinsky et al., 2004; Speechley,
2011). The scientific literature has shown broad support for the following activities to ensure the most effective, and cost-effective, fall reduction programs for community dwelling older adults: systematic fall-risk assessment, targeted interventions, exercise programs, environmental assessment, and hazard-reduction programs (Rubenstein, 2006). In an attempt to assist provider organizations with fall prevention efforts, CDC has published a “compendium” of effective fall prevention interventions for use in developing fall prevention programs for community-dwelling older adults (Stevens & Burns, 2015).
With regard to older adult fall prevention, the scientific evidence widely supports a multifactorial prevention approach that incorporates the use of evidence- supported Clinical Practice Guidelines (CPGs) to assist with the process (American
Geriatrics Society/British Geriatrics Society, 2010; Tinetti, Gordon, Sogolow, Lapin,
& Bradley, 2006). The American Geriatrics Society/British Geriatrics Society
(AGS/BGS) Clinical Practice Guideline for Prevention of Older Adult Falls, one of the several CPGs widely available for use across healthcare provider categories, is highly regarded as an evidence-based clinical approach to preventing falls in
FALL PREVENTION SERVICES FOR OLDER ADULT, AMERICAN 14
community-residing older adults (Child et al., 2012; Jones, Ghosh, Horn, Smith, &
Vogt, 2011; Laing, Silver, York, & Phelan, 2011; Vivrette, Rubenstein, Martin,
Josephson, & Kramer, 2011). These CPGs were updated in 2010 and subsequently, endorsed by the following organizations: The American College of Emergency
Physicians, the American Medical Association, the American Occupational Therapy
Association, and the American Physical Therapy Association (American Geriatrics
Society/British Geriatrics Society, 2010). Appendix A displays a step-by-step practice algorithm for fall risk screening and assessment, a companion resource for implementing the AGS/BGS Guidelines for Prevention of Older Adult Falls
(American Geriatrics Society/British Geriatrics Society, 2010).
While CPGs and algorithms for their implementation are widely available, slower than desired progress has been made in terms of closing the evidence-to- practice gaps for older adult falls prevention (Tinetti et al., 2006). There is wide variation in terms of older adult fall-prevention associated healthcare services and healthcare organizations are frequently not prepared to offer such services for their older adult patients (Fortinsky et al., 2004; Speechley, 2011). The extent to which such variation in fall-prevention services impacts services of older adult AI/ANs receiving care through Indian Health Service (IHS) funded healthcare programs is not known. However, the AI/AN older adult population is often associated with elevated unintentional injury and chronic disease burden. And based on the scientific literature, health care for AI/AN people and their corresponding Indian healthcare organizations’ ability to provide comprehensive, evidence-based healthcare across
FALL PREVENTION SERVICES FOR OLDER ADULT, AMERICAN 15
care settings is often limited by one or more of the following realities: inconsistently
offered preventive health care; limited funding for preventive services, competing
organizational challenges and healthcare priorities; limited access to health care
services due to rural, and in some situations, isolated locations, small rural clinics where primary health care providers may be expected to provide a broad array of services, including managing specialty services, and shortages of qualified health care providers (Ducore & Newsadt, 2008; Rhoades & Rhoades, 2014). Considering the recognized, aforementioned challenges that confront AI/AN serving tribal organizations and their AI/AN service population, and with an understanding of the elevated chronic disease and unintentional injury burden associated with the older adult AI/AN population, it is conceivable that evidence-to-practice gaps in terms of older adult fall prevention services exist.
Ensuring evidence-based fall prevention services for AI/ANs, an increasingly aging population burdened by disproportionate levels of chronic disease and
unintentional injury, is essential so as to effectively impact fall injury-associated
challenges, those of economic cost and those known to coincide with increased
morbidity, loss of independence, diminished quality of life. Such concern calls for further study geared toward enhancing understanding of the problem and, in-turn, offering evidence that can be used to inform the development of programs well-suited
for detecting and addressing fall-risk in older adult AI/ANs.
The availability of sound research that examines the potential influence of
certain organizational and human factors is limited and the extent to which these
FALL PREVENTION SERVICES FOR OLDER ADULT, AMERICAN 16
factors influence implementation of evidence-based practice (EBP) and adherence to
fall prevention practice guidelines is not clearly understood, yet both aspects are believed to play significant roles in care delivery and uptake (Subramanian et al.,
2007).
Rycroft-Malone et al. suggest that evidence-based, person-centered care requires the interplay of knowledge from multiple sources of evidence including the following: “research; clinical experience, patients, clients and carers; and local context and environment” (2004, p. 83). With regard to the Promoting Action
Research in Health Services (PARiHS) framework, they suggest that successful
implementation of evidence into practice is “conceptualized” to be a function of the
relationship between the nature of the evidence; the context of the setting in which change will occur; and the “mechanism by which change is facilitated” (Rycroft-
Malone et al., 2004). The original PARiHS framework did not explicitly address the prominence of the roles that individuals play in the integration of evidence into practice, however was widely used as an organizing framework to help explain and predict as to the success of moving evidence into practice (Kitson, Harvey, &
McCormack, 1998). In line with both the original PARiHS framework (Kitson et al.,
1998) and later revisions (Harvey & Kitson, 2016; Rycroft-Malone et al., 2013), the current study considered individual and organizational factors for their important
roles with regard to the “interplay” between evidence and context to promote
evidence-informed practice.
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Laing and colleagues (2011) studied fall prevention knowledge, attitude, and practices of community stakeholders and older adults in conjunction with the
Washington State Health Department. They found that 68 % of providers identified falls as an urgent health-related issue facing older adults and only 38 % indicated they were knowledgeable about recommended fall prevention practices. A low proportion of patients perceived prevention of falls to be important and, of those who had fallen, a low percentage reported individual risk assessments by their health care provider
(Laing et al., 2011).
Problem
Although several, widely-recognized, evidence-based clinical practice guidelines exist and offer promise for use in fall prevention practice, gaps with regard to implementation of such evidence into practice remain. Implementation of evidence into practice is complex, requiring a systematic, multifactorial, interprofessional approach by health care providers working across provider roles and practice settings.
Research which examines relationships between provider knowledge of, attitude toward, and practice of older adult fall prevention is limited in terms of both quantity and quality.
Purpose
The purpose of this study was to examine, within the context of tribal and
Urban Indian operated health care services, health care providers’ knowledge of, attitudes toward, and practice (KAP) of evidence-based older adult fall prevention and the potential relationships that exist between and among these concepts.
FALL PREVENTION SERVICES FOR OLDER ADULT, AMERICAN 18
Research Questions
The study sought to answer the following questions:
1. What is the relationship between health care providers’ knowledge of and
their attitude about providing evidence-based fall prevention services for older
adults?
2. What is the relationship between health care providers’ attitude about and
their self-reported organizational practice of evidence-based, older adult fall
prevention?
3. What is the relationship between health care providers’ knowledge of
evidence-based, older adult fall prevention and their practice setting
(ambulatory clinic vs community health/outreach)?
4. What is the relationship between health care providers’ knowledge of and
their self-reported organizational practice of evidence-based, older adult fall
prevention?
5. What do health care providers identify as barriers to providing recommended,
evidence-based, older adult fall prevention services?
Conceptual Framework
The Promoting Action on Research Implementation in Health Services
(PARiHS) framework was used to guide the focus of the current study and interpretation of findings. PARiHS offers a multilevel framework that considers the components of evidence, context, and facilitation, as well as their various subcomponents, to assist in conceptualizing the process of introducing identified
FALL PREVENTION SERVICES FOR OLDER ADULT, AMERICAN 19
evidence into the practice setting (Kitson et al., 1998; Rycroft-Malone, 2004). Use of
the PARiHS framework to guide the current study allowed for consideration of the
various subcomponents of each of the three aforementioned components believed to
be essential to integration of evidence into practice. With regard to the identified
phenomenon of interest, all three components of PARiHS framework are considered
essential to falls prevention practice implementation and sustainability; knowledge,
attitudes, and practice are understood to be included among important sub-factors of
the various components (Rycroft-Malone, 2004). The three core elements of the
PARiHS Framework are evidence, context and facilitation.
For the current study, the elements of “evidence” and “organizational context” were defined as per the original PARiHS framework. The element of “evidence”, as
per that framework, refers to research, clinical experience, patient preferences, and
local information (Rycroft-Malone et al., 2004). Also in line with the PARiHS
framework, the current study considers “organizational context” as “the environment
or setting in which people receive health care services” (Rycroft-Malone, 2004, p.
229). Kitson et al. (2008) suggest that “context” represents the environment in which
the change is taking place, that in consideration of culture and “relations” within the
organization. The third element, “facilitation”, was defined by these authors as “a
technique by which one person makes things easier for others” (Kitson et al., 2008).
Kitson and colleagues in their much earlier, yet significant, work suggest that this
term “describes the type of support required to help people change their attitudes,
habits, skills, ways of thinking and working” (Kitson, Harvey, & McCormack, 1998,
FALL PREVENTION SERVICES FOR OLDER ADULT, AMERICAN 20
p. 152). The authors of the PARiHS framework, based on their original and iterative
work, proposed that when the components of evidence, context, and effective
facilitation are high, the opportunity for integration of evidence into practice is also
high (Kitson et al., 1998; Rycroft-Malone et al., 2002). The researcher acknowledges
facilitation for its significance to the PARiHS framework, as a change management
strategy, and as a tool for clinical practice development, however discussion specific to this element of the model will be reserved for future study.
Specific to the PARiHS framework and to the phenomenon of interest, consideration was given to examining the relationships between and among healthcare providers’ knowledge, attitudes, and provision of evidence-based fall prevention services. Since research utilization by health care providers (HCPs) is known to play an important role in moving evidence into practice, the current study has also considered the potential influence of individual factors such as professional characteristics, educational factors, information seeking, and research involvement, those identified by Estabrooks and colleagues for their potential role as determinants of the research utilization by nurses (Estabrooks, Floyd, Scott-Findlay, O’Leary, &
Gushta, 2003).
Definitions
Fall. In line with the definition used by Tinetti and colleagues in their work,
“fall” is defined as an “event which results in a person coming to rest unintentionally on the ground or lower level, not as the result of a major intrinsic event or overwhelming hazard” (Tinetti et al., 1988, p. 1701). By embracing this “fall”
FALL PREVENTION SERVICES FOR OLDER ADULT, AMERICAN 21
definition for the current research, associated discussion was limited to falls of the
unintentional type.
Older adult. The age at which old age begins cannot be universally defined because it differs according to the context; however most developed world countries
have accepted the chronological age of 65 years as a definition of 'elderly' or older
person (World Health Organization (WHO) website, 2012). “Older adult” for the
purpose of the current study will be defined as an independent, community-dwelling
person aged 65 years or older.
Community-dwelling older adult. This term is meant to define the service
population, both in terms of age and functional status. Consistent with AGS/BGS
Older Adult Fall Prevention CPG, “community-dwelling” term is meant to exclude
from study consideration, fall prevention services provided for persons who reside in
long-term care settings and those who have cognitive impairments that limit their
ability to live independently (American Geriatrics Society/British Geriatrics Society,
2010). The community-residing, older adult (>65 years) subset was the primary focus
of the AGS/BGS Older Adult Fall Prevention CPG.
American Indian/Alaska Native. An American Indian/Alaska Native is
defined as any individual who is deemed eligible to receive health care services as an
Indian Health Service (IHS) or Tribal beneficiary.
Health care provider. Health care provider refers to any individual,
institution, or agency that provides health services to healthcare consumers ("Health
care provider," n.d.). “Healthcare provider”, for the purpose of this research, is
FALL PREVENTION SERVICES FOR OLDER ADULT, AMERICAN 22
defined as an employee of a Tribal or Urban Indian healthcare organization who, by
nature of his or her job, identifies with one of the following practice roles: Licensed
Registered Nurse (RN), Licensed Vocational Nurse or Practical Nurse (LVN or
LPN), Licensed Physician (MD and/or DO), Licensed Public Health Nurse
(RN/PHN), Licensed Midlevel Practitioner (Advanced Nurse Practitioner or
Physician Assistant), Licensed Pharmacist, Licensed Physical Therapist.
Service organization. The term “service organization” is used to identify any
Tribal and /or Urban Indian healthcare organization located within the California
Area IHS (CAIHS) service boundaries that is eligible to receive funding through
negotiated contract agreements with the Indian Health Service to provide
comprehensive, ambulatory clinic and outreach healthcare services for AI/ANs.
Urban Indian organizations are differentiated from Tribal healthcare organizations by
their funding source, oversight authority and urban Indian population served. Both
types of Indian healthcare organizations provide individual health care and in most
cases offer individual or group community programs. Since both tribal and Urban
Indian-operated types of healthcare organizations exist in California and are funded to
serve federally recognized American Indians/Alaska Natives, the current study
considered staff who are based out of either of these types of healthcare organizations
and who meet the inclusion criteria, in terms of healthcare provider practice role, as
eligible for study participation.
FALL PREVENTION SERVICES FOR OLDER ADULT, AMERICAN 23
Effective Fall Prevention. Actions aimed at reducing the number of people
who fall, the rate of falls and the severity of injury should a fall occur (World Health
Organization website, 2016).
Knowledge. Knowledge refers to the familiarity, awareness, or understanding
gained through experience or study ("Knowledge", n.d.).
Attitude. Attitude refers to a manner of thinking, feeling, or behaving that
reflects a state of mind or disposition ("Attitude," n.d.).
Evidence. Specific to the PARiHS framework, evidence refers to research,
clinical experience, patient preferences, and local information (Rycroft-Malone et al.,
2004). Using this definition associated with the PARiHS framework is important
since this particular framework was selected to guide the interpretation of study
findings phase.
Evidence-based Fall Prevention Practice/Intervention. Evidence-based
practice refers to the provision of health care that incorporates the most current and
valid research results ("Practice," n.d.). A Centers for Disease Control and Injury
Prevention report defines an evidence-based fall prevention intervention as “one that has been tested using a rigorous research design and shown to reduce falls in older adults” (Centers for Disease Control and Prevention, 2015, p. 15).
Practice. Practice is defined as the use of one’s knowledge in a particular profession; the practice of medicine is the exercise of one’s knowledge for recognition and treatment of disease (Practice, n.d.).
FALL PREVENTION SERVICES FOR OLDER ADULT, AMERICAN 24
Context. As identified by Rycroft-Malone, “organizational context” is
defined as “the environment or setting in which people receive health care services”
(Rycroft-Malone, 2004, p. 229). Using this definition associated with the PARiHS
framework is important since this particular framework was selected to guide the
process of interpretation of study findings.
Facilitator. Facilitator is defined as a person or thing that makes an action or process easy or easier (Facilitator, n.d.).
Clinical practice guidelines. Clinical Practice Guidelines (CPG), according to the Institute of Medicine (IOM) definition, are “statements of recommendations intended to optimize patient care and are informed by a systematic review of evidence and an assessment of benefits and harms of alternate care options” (IOM, 2011, p. 4)
Prevention. Prevention refers to the keeping of something (such as illness or
injury) from happening ("Prevention," n.d., p. 1).
Multiple Chronic Conditions (MCC). Multiple chronic conditions are two
or more chronic conditions that affect a person at the same time (Tinetti & Basu,
2014).
Comprehensive Fall Prevention Practice. The current study, in line with
the work of Laing et al. (2011), has considered comprehensive fall prevention to
include the following six fall prevention practice components and corresponding
definitions: “(1) individual fall risk assessment: a health care professional, such as a
doctor or nurse conducting an assessment of fall risk and then providing
recommendations on avoiding falls; (2) strength and balance training: training in
FALL PREVENTION SERVICES FOR OLDER ADULT, AMERICAN 25
special exercises to build strength and improve balance; (3) home assessment and
safety improvement: assessing and modifying the home or having someone come into
the home to demonstrate ways to protect against falling; (4) medication review and
management: having a professional (e.g., a physician or pharmacist) review medications that affect balance and help manage medications in order to prevent falls;
(5) training in assistive device (AD) use: receiving special training from a physical therapist about how to use a cane or walker; (6) fall prevention education: receiving
education that explains how to reduce fall likelihood” (p. 4). And, similar to Laing et al.’s (2011) approach, the key variables that were assessed through the on-line survey questionnaire, along with their corresponding definitions are as follows: (1) knowledge: general knowledge of recommended fall prevention practices; (2) perceived importance (attitude): assessment of the degree of importance of each of the six aforementioned FP practices; (3) provision of services and referrals
(practice): the availability of fall prevention services, frequency of available services, and whether the organization primarily refers older adults to other places offering the
FP service; (4) barriers: main reasons for not providing FP services.
In terms of health care practice setting, the following and associated definitions apply:
Community-based, ambulatory medical clinic. A community based, ambulatory medical clinic is defined as an office-based health care setting where medical services, including diagnosis, observation, consultation, treatment, intervention, and referral services are rendered on an outpatient basis, services that do
FALL PREVENTION SERVICES FOR OLDER ADULT, AMERICAN 26
not require an overnight admission, are for persons who are not confined to a hospital and who are ambulatory (Miller-Keane Encyclopedia website, 2003).
Community health/outreach department. A community health/outreach department refers to a non-stationary, non-medical clinic setting, where health care
providers, both professional and paraprofessional types, make the effort to bring
health education, health promotion, disease prevention type services or information to
people where they live or spend time.
Assumptions
The PARiHS framework, selected to guide study and data interpretation, is
based on the assumption that the concepts of evidence, context and facilitation are
discrete and interdependent and can be manipulated in a purposeful way (Kitson et
al., 2008).
Significance for Nursing
This study adds to the existing scientific knowledge base by providing
information as to the current level of elder fall prevention practice knowledge of the
targeted health care providers, and will additionally offers valuable information as to
the roles that knowledge and attitudes play in terms of evidence-based fall prevention
practice. Research evidence demonstrates that nurses, similar to other practitioners,
draw from several diverse sources of information to inform their decision-making”
(Rycroft-Malone et al., 2004). Little has been offered by way of research that leads to
a better understanding of ways in which various forms of research evidence,
including the clinical experience, contextual factors, patient experiences, and
FALL PREVENTION SERVICES FOR OLDER ADULT, AMERICAN 27
preferences influence care (Rycroft-Malone et al., 2004). Rycroft-Malone and colleagues suggest that in order to practice evidence-based, person-centered care, providers would need to “draw on and integrate multiple sources of knowledge derived from a variety of sources that have been critically and publically scrutinized”, including each of the following four different types of evidence base: Research; clinical practice, patients, clients and “carers”; local context and environment
(Rycroft-Malone et al., 2004, p. 84). These researchers proposed that delivery of individualized evidence-based health care requires professional “craft” knowledge and reasoning, however not as a stand-alone, but rather as that arrived at through a blending of the knowledge with evidence derived from each of the four aforementioned bases (Rycroft-Malone et al., 2004, p. 85).
The findings from this study offer previously unavailable information that may be valuable for those making local level decisions for grant proposals, funding and resource allocation priorities. The results will be shared broadly with administration, nurses and other health care providers. This system-wide sharing of results is important since it is through interprofessional collaboration, clinic- community health care linkages, and consideration of the important interplay of evidence, context, and facilitation that evidence-to-practice gaps can be addressed. It is anticipated that findings from this study will be useful for informing academic preparation of nurses and various other health care providers. And, will additionally spur the development of new models of care that “implicitly” acknowledge the important role of “individual” attributes, those that work interactively with evidence,
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context, and facilitation, to influence on uptake and associated integration of evidence
into practice.
Moving scientific fall prevention evidence into practice of older adult fall
prevention is known to be a complex process (Speechley, 2011). Fall prevention is
known to require a multifactorial, interprofessional approach. Estabrooks et al.
(2003) proposed that in order to increase research uptake by nurses it is necessary to
understand what individual factors influence their research utilization behaviors.
Licensed registered nurses (PHNs and Generalists), those practicing in the
ambulatory clinics and those who function in public health nursing roles associated with community health department/outreach services, are well positioned for lead roles in this area of prevention so were included in the current study along with licensed physicians, pharmacists, physical therapists, mid-level providers. This study has examined factors that may influence evidence-based, older adult fall prevention practice by nurses and other health care providers.
The findings from the study may be used to inform fall prevention research, pre-professional nursing education in academic settings, community-based fall prevention program development, provider education and quality improvement activities across healthcare settings and provider categories so as to ensure effective practice, improved access to services, and subsequent patient health outcomes related to older adult fall prevention.
Summary
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In order to keep up with health care system access and care delivery demands, health care provider’ education, training and resources must be in line with that
required by the population served. Deficiencies in any of these three component
areas will potentially negatively impact patient health outcomes. The extent to which
factors of provider knowledge of and attitude toward evidence-based, older adult fall prevention influence the level of evidence-based fall prevention practice has been unclear. Clinical practice guidelines are plentiful, health care provider education is widely available, a defined need for regularly provided fall-prevention services for the over 65 years of age population exists, and yet, the scientific evidence leads us to understand that there continues to be a lag in the integration of evidence-based, older adult fall prevention into practice. Challenges to integration may call for organizational transformation, perhaps requiring a prioritization of resources for the education and re-tooling of staff so as to ensure their preparation for keeping pace with healthcare system and service population demands.
The current study has examined and analyzed factors that may contribute to the slower than desirable progress toward closing the evidence-to-practice gaps for older adult fall prevention, that within the context of Indian healthcare. The findings from this research will be used to enhance the body of evidence, knowledge of which will bring researchers, academic faculty, organizational leaders, and health care providers closer to understanding the reasons behind the wide variation in type and quality of such services and as such, provide a basis for future program development for ambulatory-based health care organizations serving at risk populations.
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Chapter 2
Review of Literature
Purpose
The purpose of this research was to examine, within the context of tribal and
Urban Indian-operated health care services, health care providers’ knowledge of,
attitudes toward, and practice (KAP) of evidence-based older adult fall prevention
and the potential relationships that exist between and among these concepts.
Literature Review Process
A broad review of the literature was undertaken to identify research related to
fall prevention knowledge, attitude, and practices-related services of health care
providers, professionals who are actively engaged, by nature of their roles, in
providing health care services to community-dwelling older adult patients. The
researcher accessed both the National Library of Medicine’s PubMed and Cumulative
Index to Nursing and Allied Health Literature (CINAHL) data bases through the Case
Western Reserve Health Science Library link and conducted a search using the
following terms: American Indian/Alaska Native, Native American, Nurse, fall
prevention, older adult, community-dwelling, fall risk assessment, Clinical Practice
Guidelines, medication management, health care provider, nurse-led fall prevention,
“multifactorial and evidence-based fall prevention”, community-based fall
prevention, and “knowledge and attitude”. In addition, the reference lists of several
of the identified articles were examined for their relevance to the current study. A
total of 152 articles were retrieved, however once screened, approximately 95 of them
FALL PREVENTION SERVICES FOR OLDER ADULT, AMERICAN 31
were identified as relevant to the study. The searches generally included literature published within the past 10 years; however earlier articles were considered based on their relevance and contribution to the evidence base.
Phenomena of Interest
In order to effectively prevent older adult falls and subsequent fall-related injuries, health care organizations need to adopt and integrate into practice the use of evidence-based, peer reviewed, clinical practice guidelines. The literature widely emphasizes that older adult fall prevention CPGs and related practice approaches should follow a process that includes annual fall-risk assessment and identification for all persons 65 years of age and older, with related follow-up and referral, as needed, to support the reduction of fall-related injury outcomes. Together, the high level of health disparities and aging status associated with the AI/AN population offer
a compelling argument for systematic, evidence-based, approaches to fall prevention.
An aspect of fall prevention service delivery that has recently sparked interest, yet has
been minimally researched, is that associated with health care provider knowledge,
attitude, and provision of evidence-based fall prevention services (Laing et al., 2011).
This aspect of fall prevention is of interest since whether practice is based on sound
evidence is dependent, in part, on the knowledge and attitude of the health care
provider identified with such critical decisions. For the purpose of this review, the
term “health care provider” will be used to refer to licensed healthcare professionals
who, by nature of their position, in some way participate in the delivery of fall
prevention services to community dwelling older adult American Indians/Alaska
FALL PREVENTION SERVICES FOR OLDER ADULT, AMERICAN 32
Natives. The following are among those likely to be identified with such roles:
Physicians, Pharmacists, Advanced Nurse Practitioners, Physician Assistants,
Registered Nurses (generalists), Public Health Nurses, Vocational or Practical Nurses and Physical Therapists.
The PARiHS framework was identified as an appropriate tool for guiding the focus of the current project and interpretation of findings. This framework considers the components of evidence, context, and facilitation, as well as their various subcomponents, so as to conceptualize the process of introducing identified evidence into the practice setting (Kitson et al., 1998; Rycroft-Malone, 2004; Ullrich, Sahay, &
Stetler, 2014). Utilization of this multi-level framework, one of the first to focus on the explicit multi-dimensional, complex nature of implementation of evidence into practice (Harvey & Kitson, 2016), for such work related to fall prevention, allows for consideration of the various subcomponents of each of the three essential components for integration of evidence into practice. With regard to the identified phenomena of interest, the evidence and context components of the PARiHS framework are understood by the researcher to be particularly relevant to this study; the “facilitation” component is essential to implementation and sustainability however due to limited resources with be reserved for future study.
Older Adult Falls as a Public Health Concern
Unintentional falls in the older adult population are of major public health concern, with about one in three persons over the age of 65 years experiencing a fall event each year (American Geriatrics Society/British Geriatrics Society, 2010;
FALL PREVENTION SERVICES FOR OLDER ADULT, AMERICAN 33
Rubenstein & Josephson, 2006; Scott, 2013; Stevens, Noonan, & Rubenstein, 2010).
Recent national vital statistics data, those compiled by the Centers for Disease
Control and Prevention (CDC), identify falls as the leading cause of unintentional
injury death for AI/AN adults ages 65 years and older (National Center for Injury
Prevention and Control: Data & Statistics (WISQARS) website, 2015). As early as
2001, the California Department of Public Health identified falls as the leading cause
of non-fatal hospitalized injuries and the “dominant” injury cost in California (Ellis &
Trent, 2001).
More recently, a 2014 report of California data identifies falls in the over 65
years of age cohort with leading injury-related cause of death and medical care use
(Wallace). That same report calls attention to the 1,819 fall-related deaths, more than
72,000 fall-related hospitalizations and more than 185,000 fall-related emergency
department visits; those events occurred during 2012 and associated with the 65 years of age and older population (Wallace, 2014). U.S. Census Bureau data identifies fall injuries as a major threat to the health and quality of life of 3.7 million older adult residents (U.S. Census, 2014). Satter et al., in their article focusing on California residents, report that one in five AI/ANs 65 years of age and older have reported multiple falls in the past year; reportedly the highest prevalence of any racial or ethnic group (Satter, Wallace, Garcia, & Smith, 2010). Their findings suggest that similar to all older adults in California, only about half of AI/AN older adults received medical care associated with their falls (2010).
Fall Risk and Chronic Disease
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Injury and population trends associated with a population known to be heavily burdened by chronic health conditions such as diabetes, cardiovascular disease, and obesity, call attention to the need for new and improved measures for appropriately addressing the health care needs of the AI/AN population. Fall risk is increased for older adults who endure such chronic health conditions since these chronic conditions and normal aging process are both independently associated with elevated risk for unintentional falls. Although age alone is not a determining factor for fall risk, certain conditions associated with the normal aging process are known to increase fall risk (Tinetti et al., 1988). Older adults are believed to be at increased risk for falls and fall-related injuries based on the assumed likelihood that they are less physically active due to musculoskeletal problems, are more frequently prone to suffer from declining physical health, and/or are more likely to suffer from gait and balance disorders. Older adult falls are frequently associated with reduced functionality, morbidity, mortality, and premature nursing home placement (Rubenstein, 2006).
Evidence leads the researcher to understand that falls and resulting injuries can generally be prevented through changes in behavior, changes in health care delivery approaches and with modification to the environment (Scott, 2013; Speechley, 2011).
Aging, Chronic Disease, and Fall Risk
The number of individuals age 65 years in both the general population and that of the American Indian/Alaska Native population is expanding, with projections suggesting an increase of 12.5 % between years 2000 and 2050 (U.S. Census, 2000).
Each year, approximately one in three persons at or above 65 years of age endures a
FALL PREVENTION SERVICES FOR OLDER ADULT, AMERICAN 35
fall (Registered Nurses’ Association of Ontario, 2005; Stevens et al., 2010). And, of those who fall, approximately 20 to 30 % suffer from a serious fall-related injury that requires medical intervention (Tinetti et al., 1988).
With regard to the American Indian/Alaska Native population, unintentional injuries remain high; unintentional falls was ranked as the leading cause of injury death in 2015 (Centers for Disease Control and Prevention [CDC], 2016). Such alarming statistics call attention to the importance of identifying fall-risk and ensuring appropriate intervention for older adult AI/ANs and other at-risk populations. Fink and Bill (2013) suggest that such preventative services should reach beyond the clinic and into the community health side of healthcare organizations. The population targeted to receive the services being considered through this research is that of the
AI/AN population, one identified by Renfro and Fehrer (2011) to be at elevated risk for falls and fall-related injuries, in part, by nature of their overall chronic disease burden. This review of relevant literature has been extremely important for the purpose of identifying best approaches to fall prevention in the AI/AN at-risk population, one burdened with excessive rates of chronic disease, including diabetes, cardiovascular disease, and obesity.
The general literature confirms that fall prevention services are not being offered to the extent required in order to meet the needs of an increasingly aging, at risk population. The literature suggests that the reasons for such disparities with regard to older adult fall prevention services are not fully understood. Tribal healthcare organizations are frequently associated with limited resources, staffing
FALL PREVENTION SERVICES FOR OLDER ADULT, AMERICAN 36
shortages, lack of clinical practice guidelines, lack of process-based care, an
increasingly aging and at-risk patient population, and elevated health care costs, all of
which place a heavy burden on a system expected to meet the demands of the
corresponding patient population (Berger, 2013; Ducore & Newsadt, 2008; Finke &
Bill, 2013). Prevention and public health continue to be emphasized as high priorities
by the Indian Health Service and many tribal organizations (Dixon & Roubideaux,
2001; Finke & Bill, 2013; Rhoades & Rhoades, 2014).
A “team-based”, systematic approach to fall prevention services is essential,
preferably one that incorporates the use of evidence-based clinical practice
guidelines. Rycroft-Malone (2004) emphasized that this approach must be informed
by scientific evidence in combination with expert clinical decision-making.
However, implementation of practice guidelines is not as “straightforward” as simply
offering CPGs, followed by education on the guidelines, but rather that it requires
intense consideration of “key factors”, those of evidence, context, and facilitation and
the corresponding sub elements (Rycroft-Malone, 2004, p. 298). Kitson et al. (1998)
were the original developers of the “Promoting Action on Research Implementation
in Health Services” (PARIHS) Framework; Rycroft-Malone and colleagues further
developed the “multidimensional” framework to include analysis of the three
dimensions and studied its content validity (Rycroft-Malone, 2004).
Evidence-based strategies for prevention of unintentional falls in community
dwelling older adults frequently include annual fall-risk screening for all persons 65
years of age and older, appropriate follow-up assessment of and interventions for
FALL PREVENTION SERVICES FOR OLDER ADULT, AMERICAN 37
patients identified to be at risk for falls, medication management and medication
reduction.
The literature review was focused on the following practice components of
fall prevention: fall risk screening, use of evidence-based clinical practice guidelines, medication management and annual fall-risk screening. This next section of the
review will allow for discussion of the evidence in terms of the following concepts as
to their potential influence on older adult fall prevention: health care providers’
knowledge of older adult fall prevention, health care providers’ attitude toward older adult fall prevention, health care providers’ practice of older adult fall prevention, and the relationships between and among concepts. This review did not include in-depth discussion of gait and balance components and topics specific to medical
management of fall prevention. However, since these practice components are
known to be essential to effective evidence-based fall prevention, the survey
instrument for the current study was designed to capture healthcare providers’
knowledge, attitude, and practice with such regard.
Fall Risk and Practice
A wide variety of approaches to the practice of older adult fall risk detection
and prevention are being utilized and there is an ongoing lag in integration of the
scientific evidence-base into fall prevention practice, including the practice of
providing individual fall risk assessments. Evidence-based guidelines for assessing
the risk for falls in older adults are widely available; however screening rates
continue to be lower than desirable (Rubenstein, Powers, & MacLean, 2001; Centers
FALL PREVENTION SERVICES FOR OLDER ADULT, AMERICAN 38
for Disease Control and Prevention [CDC]). Ploeg and colleagues reported that
factors influencing the use of evidence-based clinical practice guidelines continue to
be poorly understood and an understanding of facilitators and barriers is “critical” for
the development of effective guidelines and their implementation (Ploeg, Davies,
Edwards, Gifford, & Miller, 2007). These same authors emphasized that implementation of guidelines should address “barriers related to individual practitioners and social, environmental and organizational context” (Ploeg et al.,
2007, p. 210). Facilitators and barriers were understood to be those associated with staff attitudes, beliefs, and team collaboration, organizational constraints, and
guideline implementation (Ploeg et al., 2007).
Demons and Duncan (2014) emphasized the need for health care professionals
to specifically inquire about falls, since patients are often not forthcoming about their
fall history or functional decline that may in fact elevate their fall risk. They
suggested that “front line providers have the opportunity to identify risk and intervene
at the earliest signs of change in a person’s condition” (Demons & Duncan, 2014).
However, the National Committee for Quality Assurance ([NCQA] (2013) found that
practitioners discussed risk of falls with only about one-third of Medicare enrollees
for whom such a discussion would have been appropriate.
Jones and colleagues (2011), in a study of physicians’ knowledge, attitudes,
and practices of fall risk assessment, found the majority of physicians did not report
the use of any CPGs, most physicians reported screening for falls only for those
patients who expressed concern over falling, rarely was fall prevention information
FALL PREVENTION SERVICES FOR OLDER ADULT, AMERICAN 39
offered to the patients, and physicians who accepted Medicare were significantly
more likely to refer patients for a home safety assessment than physicians who did not
accept Medicare.
Falls are usually the result of the interaction of various risk factors and
situations that in many cases can be corrected or modified so as to reduce risk. Such
risk factors are often enhanced by conditions associated with age, disease and hazards
in the environment (Dionyssiotis, 2012). The incidence of falls is known to increase
with the number of risk factors present. Tinetti, Williams, and Mayeswski (1986), in
a study designed to identify the individual chronic characteristics associated with falling among elderly persons and to test the hypothesis that risk of falling increases as the number of chronic disabilities increases, found that at least among some elderly
persons falling appears to result from the “accumulated effect of multiple specific disabilities”. These authors suggested that in terms of the chronic disabilities under
consideration in their study, some may be remediable (1986). The also reported that
in addition to chronic factors, acute illnesses may play a role in determining fall risk
(Tinetti et al., 1986).
In a 1985 study, Tinetti, Speechley and Ginter found that the incidence of falls
was 8% among persons with no identified risk factors and 78% among those with
four or more risk factors (Tinetti et al., 1988). Intrinsic risk factors such as falls
history, age, medication usage, nutritional deficiencies, and cognitive disorders are
associated with increased fall risk; extrinsic risk factors are those associated with the
environment and can also be modified to reduce fall risk (Tinetti et al., 1988).
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Approaches for Fall Risk Identification, Assessment and Management
Older adult fall prevention is complicated, requiring a multifactorial, interprofessional approach to risk identification, assessment and management.
Frequently, in community health settings, fall risk-related interventions need to be
tailored to meet the needs of the individual, services which may require health care
provider attention to one or more of the components of risk.
Within the IHS system of health care, practice gaps in terms of screening for
fall risk and medication management exist. Data specific to California AI/ANs
suggest that only one quarter of AI/AN elders have had a health care professional
review their medications after a fall; this low rate for such activity may be associated
with the fact that seniors often do not report a fall unless seeking fall-related medical
care (Satter et al., 2010). Considering the wide array of clinical practice
recommendations that call for medication review and management for all at-risk
patients, this reported rate of screening is lower than desirable and not consistent with
current recommendations. On the other hand, Tinetti and others have found through
their research that nationally, physicians find conducting a comprehensive medication
review time-consuming, are not always familiar with current protocols, and may not
be familiar as to billing procedures for such activity (Tinetti, Gordon, Sogolow,
Lapin, & Bradley, 2006).
At the same time, organizations are being challenged to meet various care-
quality benchmarks, among which are provider and patient services incentives funded
through CMS. In terms of incentives and opportunity, the Affordable Care Act of
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2010 included the following provision intended to improve health and prevent
chronic health conditions, the Medicare Annual Wellness Visit that includes a Health
Risk Assessment and a Personalized Prevention Plan (Sebelius & Koh, 2010). This provision, enacted in 2011, offers the opportunity for medical providers to be reimbursed under Medicare for ensuring an Annual Wellness Visit (AWV) for their
Medicare eligible patients. While the AWV does not specifically call for a fall risk assessment, it does offer an annually reimbursed, focused opportunity for taking a medical history and developing a preventive screening schedule for Medicare
enrolled patients (Sebelius & Koh, 2010). The reimbursed Annual Wellness Visit
also provides an opportunity for patient and physician to discuss ways to prevent disease and access recommended preventive services (Benson & Aldrich, 2012). The
ACA provisions for a Medicare-reimbursable initial screening upon entry into
Medicare, the Annual Wellness Visit, and the Personalized Prevention Plan offer
unique opportunities for health care providers to assess for potential fall risk factors.
Although these visits are currently available through CMS, patient and provider
challenges will most likely determine their uptake. Staff, administration and patients
have a shared responsibility for meeting care quality mandates related to fall prevention through participation in comprehensive, multifactorial fall prevention services.
Clinical Practice and Fall Prevention Practice Guidelines
As previously noted, across the healthcare spectrum there are serious gaps between scientific evidence and current levels of clinical practice (Irving et al., 2006;
FALL PREVENTION SERVICES FOR OLDER ADULT, AMERICAN 42
Rycroft-Malone et al., 2002). CPGs, according to the Institute of Medicine definition, are “statements of recommendations intended to optimize patient care and are informed by a systematic review of evidence and an assessment of benefits and harms of alternate care options” (IOM, 2011, p. 4). Several of the articles under review made reference to CPGs from the American Geriatric Society/ British
Geriatrics Society, the U.S. Preventive Task Force, the Registered Nurses Association of Ontario and the Centers for Disease Control and Prevention (Child et al., 2012;
Scott, 2013; Registered Nurses’ Association of Ontario, 2005; Stevens et al., 2010;
U.S. Preventive Services Task Force website, May 2012; Vivrette et al., 2011). Ploeg and colleagues, in their study of factors influencing CPG implementation, found there to be a plentiful supply of evidence-based CPGs, however that the implementation of these guidelines into practice is fragmented and incomplete (Ploeg, Davies, Edwards,
Gifford, & Miller, 2007). In line with this, Rycroft-Malone has suggested that “it should not be assumed that providing clinical practice guidelines” or “developing providers skills to appraise research will lead to greater use of evidence” (Rycroft-
Malone, 2008, p. 404). Ploeg et al. (2007) additionally emphasize that in order to ensure effective guideline implementation, strategies should ensure that all staff are included and that they have a clear understanding of barriers and facilitators.
Of the older adult fall prevention clinical practice guidelines that exist, the
American Geriatric Society/British Geriatrics Society (AGS/BGS) and U.S.
Preventive Task Force (USPTF) Guidelines (American Geriatrics Society/British
Geriatrics Society, 2010; U.S. Preventive Services Task Force website, May 2012)
FALL PREVENTION SERVICES FOR OLDER ADULT, AMERICAN 43
have been identified as appropriate for use by health care professionals providing fall
prevention services for community-residing older adult AI/AN patients (Finke & Bill,
2013; Scott, 2013). Based on the strength of recommendation, the AGS/BGS
Guidelines are broadly supported for guiding clinical approaches to reducing fall risk in older adults and are widely used across professional disciplines (Child et al., 2012;
Jones, Ghosh, Horn, Smith, & Vogt, 2011; Laing, Silver, York, & Phelan, 2011;
Vivrette, Rubenstein, Martin, Josephson, & Kramer, 2011). Finke and Bill (2013), emphasize that fall prevention efforts should reach beyond the clinic and into the community health side of health care organizations. Appendix A displays the algorithm for fall risk screening and assessment; a tool that is offered as a component of the AGS/BGS Clinical Practice Guidelines for Prevention of Older Adult Falls
(American Geriatrics Society/British Geriatrics Society, 2010).
Medication Management
The scientific evidence offers broad support for medication management for reducing unintentional falls; however this can be complicated due to the elevated polypharmacy evident within the AI/AN population, a population frequently burdened with complex medical conditions that often require a correspondingly elevated number of medications (Tinetti et al., 1993; Chiang-Hanisko, Tan, &
Chiang, 2014). One author addressed the issue of medication management through a study on in-home medication reviews which demonstrated that an in-home outreach can be successfully performed by trained student volunteers and suggests that this
FALL PREVENTION SERVICES FOR OLDER ADULT, AMERICAN 44
was an application of a patient centered home model to improve patient safety
(Willis, Hoy, & Jenkins, 2011).
According to Dionyssiotis (2012), the risk of falling increases significantly in patients who are taking more than four medications of any type. Dionyssiotis (2012) and other researchers suggest that, as the number of factors associated with fall risk increase, so does the risk of falling (Tinetti et al., 1988; Tinetti, Williams, &
Mayewski, 1986). Consistent with this thinking, Diolyssiotis (2012) recommended multifactorial fall prevention programs, rather than those singling out pharmacological treatment as a method for successfully reducing incidence of falls.
Fall Risk Factor Identification
“Fall” has been defined as an “event which results in a person coming to rest unintentionally on the ground or lower level, not as the result of a major intrinsic event (such as a stroke) or overwhelming hazard”, a definition that most accurately reflects the direction of the problem statement (Tinetti, Speechley, & Ginter, 1988, p.
1701). Widely accepted fall-risk factors include: muscle weakness, a prior history of falls, difficulties with gait and balance, visual impairment, arthritis, functional limitations, depression, and the use of psychotropic medications (American Geriatrics
Society/British Geriatrics Society, 2010).
The risk of falling is increased in accordance with the number of fall-related risk factors present; factors may be associated with normal aging, yet frequently are the result of chronic conditions (Ganz, Alkema, & Wu, 2008; Tinetti, Williams, &
Mayewski, 1986). Tinetti, Williams, and Mayewski in their 1986 article, suggested
FALL PREVENTION SERVICES FOR OLDER ADULT, AMERICAN 45
that if the factors associated fall risk can be recognized, then there is a possibility that
“at least some falls, and their associated consequences can be prevented through appropriate interventions. Multifactorial risk assessment offered in conjunction with targeted fall prevention interventions that include the following components is evidenced to have a significant impact on preventing falls and reducing serious fall- related injuries: exercise and physical activity, medical assessment and management, medication adjustment, environmental modification, and education (American
Geriatrics Society/British Geriatrics Society, 2010). Comprehensive fall prevention includes the following components: Physical activity which includes balance and mobility training, risk assessment and medication management; and in-home environmental modification (Fall Prevention Center of Excellence, 2015). A coordinated, multidisciplinary approach by health care providers working across settings is “key” to successful fall prevention (Shubert, Smith, Prizer, & Ory, 2013;
Ganz et al., 2008).
Fall-Risk Screening
Although the evidence base indicates that multifactorial interventions are effective in reducing the incidence of falls, Rubenstein et al. (2004) concluded from their study that under-detection and inadequate evaluation by community physicians appears to exist. They suggested adherence to practice guidelines for fall risk detection, evaluation, recommendations and treatment in order to improve outcomes in community-dwelling older adults (Rubenstein et al., 2004).
FALL PREVENTION SERVICES FOR OLDER ADULT, AMERICAN 46
Gaboreau et al. (2016) concluded from their study of factors affecting implementation of annual screening for falls among older adult patients, that General
Practitioners (GPs) are widely aware of falls in the elderly, the prevalence of the
problem, and the usefulness for annual screening and yet only one in four GPs
implemented annual screening. They found that GPs seemed to have reservations as
to the usefulness of practice guidelines and implementing annual fall-risk screening
for older adults and concluded that GPs should consider fall assessment as a basic
element of medical care for patients 65 years of age and older (2016).
A cross-sectional study of emergency room physicians found that inadequate
referral sources, multiple medications, low patient compliance, and lack of medical
reimbursement were the most commonly reported barriers to fall risk assessment and
management (Fortinsky et al., 2004). History of falls should be included in annual fall-risk screening because history of falling is strongly associated with fall risk
(Shubert, Smith, Prizer, & Ory, 2013; Barry, Galvin, Keogh, Horgan, & Fahey, 2014;
Vivrette et al., 2011). One article called for screening for fall-related risk as a first step to target care to a specific population that may need follow-up fall risk assessment and treatment (Shubert, Smith, Prizer, & Ory, 2013).
The literature emphasizes the importance of early fall-risk screening for its significant impact on reducing fall-risk, fall rate, and injury or death from falls
(Dionyssiotis, 2012; Renfro & Fehrer, 2011; Shubert et al., 2013). Shubert and colleagues discussed the importance of an annual wellness visit as an appropriate time to be screened for fall risk and associated it with Centers for Medicare and Medicaid
FALL PREVENTION SERVICES FOR OLDER ADULT, AMERICAN 47
(CMS), Meaningful Use incentives, suggesting that those who perform a wellness visit will be reimbursed (Shubert et al., 2013; Centers for Medicare & Medicaid
Services [CMS], 2012). These same authors report that although screening is part of the initial Medicare Wellness Visit, it is not standard among most providers and is not a standard part of medical school training (Shubert et al., 2013).
Current Knowledge
The majority of falls in community-dwelling older adults can be prevented, an abundance of evidence-based tools and resources available to health care providers for use in addressing the problem of older adult falls exist (American Geriatrics
Society/British Geriatrics Society, 2010; Registered Nurses’ Association of Ontario,
2005; Stevens, 2010), and regardless of this evidence, gaps between what is known and what is applied through everyday practice remain. Researchers, when attempting to explain older adult fall prevention evidence-to-practice gaps, frequently cite healthcare organizations’ lack preparation for offering comprehensive fall prevention services for the older adult segment of the population (Shubert et al., 2013; Stenberg
& Wann-Hansson, 2011). For American Indians/Alaska Natives (AI/ANs) who receive care through tribal and Urban Indian-operated healthcare organizations and for the corresponding Indian healthcare organizations, such is an issue of broad concern. Falls are a leading cause of unintentional injury death in AI/ANs over 65 years of age (Centers for Disease Control and Prevention [CDC], 2016).
The cost of falls is an additional burden to an already resource-burdened system of care. The costs associated with treatment for related injury, with loss of
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productivity for the faller, and those related to human suffering are cause for concern and related action. The average hospital cost for a single hospitalization from a “fall” injury is over $30,000 (Burns, Stevens, & Lee, 2016). In 2008, the Indian Health
Service Injury Prevention (IP) program identified older adult falls prevention as one of the two IP program priorities at which time the aim was to develop a comprehensive approach to ensuring older adult, community dwelling, fall prevention services. With older adult fall prevention identified as an IHS/IP program priority, the program’s focus on environmental risk assessments and associated follow-up intervention was expanded to include a plan for developing a comprehensive approach to the prevention of fall-related injuries for older adults living in AI/AN communities (Bill & Finke, 2010).
With advances in health care, American Indians and Alaska Natives on the average are living longer; many of whom are heavily burdened by co-morbidity of chronic diseases such as cardiovascular disease, diabetes, and behavioral health conditions. The disproportionate level of chronic health conditions such as diabetes, obesity and cardiovascular disease has had a devastating impact on this population in terms of not only the disease itself, but also in terms of the increased underlying risk for falls and related injuries. Systematic, organizational approaches, CPGs and resources for implementing such guidelines for older adult fall prevention are frequently not evident (Ducore & Newsadt, 2008). Evidence based, peer reviewed fall prevention guidance that is well-suited for use in IHS and Tribal clinics has been published; however national quality guidelines such as GPRA measures do not
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currently address older adult fall prevention. In response to a concern over impact of fall-related injuries on American Indians and Alaska Natives, in 2010 the IHS Injury
Prevention Program and the IHS Elder Health Consultant convened a workgroup composed of IHS, Tribal and National level stakeholders, who together identified a comprehensive approach and corresponding evidence-based practice resources for health care provider use in clinical and community health fall-prevention practice
(Finke & Bill, 2013). This integrated, collaborative approach to ensuring availability of evidence-based resources for practice is consistent with the IHS agency priorities and goal of ensuring that comprehensive, culturally acceptable personal and public health services are available and accessible to American Indian and Alaska Native people (Indian Health Service website, n.d.).
Influence of Health Care Provider Knowledge on Older Adult Fall Prevention
Even though evidence based practice guidelines are widely available, rates of screening for older adult falls are low, physicians lack the knowledge to perform screening, and physicians rely on peers rather than medical literature to inform practice (Demons & Duncan, 2014). Many primary care physicians may not know how to conduct fall risk assessments or have necessary knowledge to intervene in terms of fall prevention (Chou, Tinetti, King, Irwin, & Fortinsky, 2006; Fortinsky et al., 2004).
Chou et al. (2006) reported that physician barriers and facilitators include awareness, competing risks, appropriateness of referrals and training. However, they
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also noted limited ability to draw conclusion from their study based on a low
participant response rate and qualitative study design (Chou et al., 2006).
Laing and colleagues (2011) studied fall prevention knowledge, attitude, and
practices of community stakeholders and older adults in conjunction with Washington
State Health Department. Theirs is one of the few studies that obtained, by way of
phone survey, feedback as to knowledge of and attitudes about falls prevention from
older adult patients as well as their care provider stakeholders. Based on survey results from their study, health care providers self-reported having only 37% knowledge with regard to the practice of older adult fall prevention (Laing et al.,
2011).
A systematic review and synthesis of qualitative studies exploring factors influencing implementation of fall prevention evidence into practice, suggested that successful implementation requires individuals, professionals and organizations to modify established behaviors thoughts, and practices (Child et al., 2012). Efforts to improve the identification of factors influencing the implementation of fall prevention programs requires understanding of the barriers and facilitators that “help or hinder” the evidence-to-practice gap (Childs et al, 2012). Jones and colleagues (2011)
suggested targeted education and training on updated clinical guidelines and materials as a means to increasing awareness of study participants.
Attitudes and Practice Behaviors
Speechley (2011) suggests that improving delivery of preventive health care requires a change in attitudes and behaviors and an understanding of the system level
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characteristics that influence these attitudes and behaviors. Estabrooks et al. (2003)
considered attitudes and beliefs to be among the various potential determinants of
research utilization practice, those in addition to professional characteristics, educational factors, information seeking, socio-economic factors, and research
involvement. A Registered Nurses Association of Ontario publication pointed out
that knowledge, skills, and attitudes of healthcare professionals “could” affect their
motivation with regard to the implementation processes of new clinical practices
(Registered Nurses’ Association of Ontario, 2002). Similarly, Stenberg and
colleagues suggest that further knowledge is needed in terms of the influence of
healthcare professional attitudes on implementation of CPGs into practice (Stenberg
& Wann-Hansson, 2011).
A study of attitudes of physicians practicing in rural Florida, reported overall
negative perceptions and opinions about the elderly population. The authors noted
that such attitudes could negatively impact care, especially in situations where these physicians were the patients’ sole source of health care, managers of “their health care needs” and suggested additional research with regard to the effects of “Ageism” on practice (Gunderson, Tomkowiak, Menachemi, & Brooks, 2005).
Attitudes and Recommended Fall Prevention Practice
Whether or not knowledge of evidence-based fall prevention practice guidelines influences or is influenced by associated provider attitudes and practice is unclear. However, it is likely that the intentions and behavior of health care providers
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are influenced by measurable psychological variables, including their attitudes, just as such variables influence the behavior of any individual (Marteau & Johnston, 1990).
Kortteisto and colleagues identified the need to better understand the problems of implementation that relate to professional attitudes and experiences associated with use of CPGs in a healthcare context (Kortteisto, Kaila, Komulainen, Mantyranta, &
Rissanen, 2010). They found that compared with other professionals, nurses and physicians had positive intention to use clinical practice guidelines, and that not all provider types will benefit from same implementation strategies.
Vivrette et al. (2011) reported that patients expected physicians to be the motivators of fall-prevention behavior, felt that information would be well received from this source and expressed dissatisfaction when doctors did not routinely address fall prevention during office visits. They also found that participants reported a lack of attention to fall prevention in primary care settings and suggested that future studies should look at the impact of brochures and other resources on encouraging behavior change (Vivrette et al., 2011).
Ganz and colleagues offer the World Health Organization Innovative Care for
Chronic Conditions (ICCC) as a framework for looking at falls prevention from both the clinic and community health perspectives (Ganz, Alkema, & Wu, 2008). Their work with regard to falls prevention focuses on identifying and taking action on the source of risk whether by adapting new practices as a provider or by changing lifestyle as a patient (Ganz et al., 2008). These shifts in practice by the health care provider and changes in patient lifestyle called for in that model are concepts closely
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aligned with, and potentially informed by knowledge of and attitude about evidence- based best practices in falls prevention.
The contextual factors that potentially influence fall prevention activity are considered important to both the PARiHS and ICCC frameworks (Ganz et al., 2008;
Rycroft-Malone, 2004). With similarity to Rycroft-Malone and colleagues findings,
Ganz et al. identified staffing ratios, face-to-face time with patients, organizational resources and culture, leadership styles, and internal organizational processes as those factors that can either hinder or promote fall prevention services and related uptake
(Ganz et al., 2008, p. 7; Rycroft-Malone, 2004).
Jennifer Dempsey suggested that while issues related to staffing and patient demands may be influential on patient fall outcomes, “they do not completely explain the situation” (2004, p. 484). She further suggested that predicted trends in falls demonstrate the need for action to address systems that are struggling to meet current demands, those in part related to nursing staffing shortages (Dempsey, 2004). A study of nurses’ perceptions, knowledge and barriers to adopting EB practice in clinical decision making, found that although nurses’ responses reflected a positive attitude toward EBP and that they considered it fundamental to practice, several institutional and personal barriers related to not having dedicated time for training on, learning and implementing new EB techniques, influenced implementation (Majid et al., 2011). Majid and colleagues concluded that when confronted with the knowledge of such potential barriers, management could overcome most barriers by modification
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of staffing schedules to provide an environment conducive to socializing
opportunities for nurses to promote peer-to-peer information and knowledge sharing.
Health Care Provider Knowledge, Attitudes, and Practice
In order to meet the access and care delivery demands that potentially impact patient care outcomes, health care professionals’ knowledge, training and practice resources must reflect current evidence and be supported by organizational resources.
With such regard, the literature suggests that knowledge, skills and attitudes of health care professionals have been shown to affect motivations related to the process of implementing new clinical practices (Registered Nurses’ Association of Ontario,
2005). Such potential challenges may influence healthcare organization transformation in terms of decisions associated with identification of priorities related to resource allocation and staff development.
The PARiHS framework calls for the following three focus areas to be considered when implementing practice changes: evidence, context and facilitation
(Rycroft-Malone, 2004). For the purpose of the current research, the PARiHS conceptual framework, along with the American Geriatric Society/British Geriatric
Society’s (AGS/BGS) Clinical Practice Guidelines for Preventing Older Adult Falls
were used to guide the research process. As evidenced through the earlier cited
appendix A, the AGS/BGS CPGs incorporate the following six practice components
within its’ guidelines for preventing falls and fall injuries: individual risk assessment,
strength and balance exercises, home assessment and improvement to home safety,
review and management of medications that affect balance, gait training and training
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on the use of assistive devices, and fall prevention education (American Geriatrics
Society/British Geriatrics Society, 2010).
Falls prevention has been identified as a nursing-sensitive quality indicator, perhaps more specific to hospital-based care; however, in terms of nursing quality, such designation has relevance for practice based in the clinic and community health settings (Heslop & Lu, 2014). Nurses based within ambulatory care clinics, as well as those who occupy positions in community based outreach departments, are well suited and situated for lead roles in a variety of aspects of fall prevention practice.
Nurses in these positions have the opportunity to bridge practice gaps that exist across settings by participating as full partners in terms of responsibility for ensuring the coordination and practice of fall-risk screening, assessment, and associated interventions. With a minimal amount of targeted training and content-specific continuing education, nurses are well prepared to assume roles of ensuring that annual fall risk screening, fall prevention education and medication reconciliation are not overlooked. Despite the fact that nurses are known to play major roles with regard to falls prevention, the researcher has chosen to draw from peer-reviewed literature that acknowledges the widely-accepted belief that a coordinated, multifactorial, interprofessional, team-based approach is essential to effective fall prevention practice.
Prevention of older adult falls is a multifactorial and interprofessional, sometimes referred to as multidisciplinary, effort. A team-based, systematic approach to older adult fall prevention that incorporates the use of evidence-based
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clinical practice guidelines is believed to enhance patient outcomes. Of additional importance is that the approach be informed by scientific evidence and expert clinical decision-making. Since CPGs are identified as an important component of older adult fall prevention practice, the literature review process included a review of some of the more widely identified evidence-based practice guidelines specific to prevention of older adult falls and fall-related injury. The scientific evidence offers strong support for annual fall risk screening for all persons 65 years of age and older, that with appropriate follow-up assessment and interventions once elevated fall-risk is identified.
Several organizations have offered highly recognized, scientific evidence- based clinical practice guidelines outlining strategies for older adult fall risk identification and fall prevention. As a result of the widely-available CPGs, an extensive number of published studies discuss organizational attempts at guideline implementation within the United States as well as internationally. An extensive review of literature has revealed that the overall progress related to implementation of these guidelines over the past decade has been slow, with significant gaps remaining between the evidence and actual practice of evidence-based older adult fall prevention. One group of researchers suggest that the “difficulties faced by primary care providers in caring for patients with regards to falls is part of a larger problem of adhering to clinical guidelines for any condition” (Kramer et al., 2010, p. 312).
As far back as the late 1990s, researchers looked at barriers to clinical guideline implementation, concluding that these barriers fall into the following three
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categories: Knowledge, attitudes, and behaviors (Cabana et al., 1999). Baker and
colleagues (2005) found from their study that in terms of knowledge, some providers
might not be aware that falls are preventable. Another group of researchers suggested
the following as potential barriers to implementation work in terms of the category of
“behavior”: patients frequently do not report fall events, patients often present with
multiple/competing problems, and clinical system reminders for prompting or alerting
providers’ as to need for intervention are frequently not in place (Chou, Tinetti, King,
Irwin, & Fortinsky, 2006).
Consistent with national healthcare trends for the overall U.S. population,
efforts to ensure scientific evidence-based fall prevention services for older adult
AI/ANs have been sporadic. And, although limited resources are frequently cited as
the reason for service gaps across all categories, the extent to which organizational
and human factors influence services made available to independent, community-
dwelling, older adult AI/ANs who receive care through tribal and Urban Indian-
operated ambulatory-based healthcare clinics is largely unknown.
Summary
This review offered the opportunity to obtain a clearer understanding of falls, fall risk, and fall prevention practice issues from both empirical and theoretical research perspectives. The extensive review of literature revealed that falls prevention is a complex, multifactorial problem that, consequently, requires a team- based, multiprofessional approach across various practice settings. National, state, and AI/AN life expectancy and disease trends, those consistent with elevated fall risk,
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bring attention to the lagging uptake of evidence-based practice and need for
improved approaches for addressing older adult fall prevention. More specifically, the review of literature afforded the researcher the opportunity to take a closer look at research focused on health care provider knowledge about, attitude toward and
practice of older adult fall prevention and ways in which these three factors interplay
to determine practice outcomes.
Clear evidence exists with regard to the sufficient number of high quality,
evidence-based Clinical Practice Guidelines for general use in practice. Additionally,
algorithms and frameworks for simplifying the use of these CPGs for identifying fall risk and providing needed follow-up based on the guidelines are widely available.
Resources for ensuring appropriate staffing levels, staff and patient training and
continuing education, availability of fall-risk assessment tools, and patient
resources/equipment are often limited (Ducore & Newsadt, 2008). Organizational
leadership decisions frequently influence the type and number of health care services
that are available. Given the suboptimal amount of evidence-based, peer-reviewed
literature available on the topic, the extent to which knowledge of, attitudes about,
and engagement in older adult fall prevention practice informs level of service or
patient outcomes remains unknown. These factors, in addition to those earlier
discussed, may very well determine the level of fall prevention services offered and/
or accessible to those in both the general population and smaller AI/AN subset.
Patients and health care providers have a shared responsibility for ensuring
that evidence-based, peer-reviewed, clinical practice guidelines for falls prevention
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are successfully implemented and effective. Attitudes and behaviors of individuals, including those of both patients and healthcare providers, are known to influence practice levels, patient engagement, and retention with regard to preventive health interventions. This review of literature only briefly touched on older adults’ knowledge, attitudes and practices related to fall prevention since it was outside the scope of the current research study. Due to the potential implications of the phenomenon of interest in terms of the future of fall prevention and more importantly patient health outcomes, additional evidence-based research that focuses on knowledge, attitude, and fall prevention practices of older adults and their
corresponding health care organizations is needed.
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Chapter 3
Methods
Purpose
The purpose of this study was to examine, within the context of tribal and
Urban Indian-operated health care services, health care providers’ knowledge of, attitude toward, and practice (KAP) of evidence-based, older adult fall prevention and the potential relationships that exist among and between these concepts.
Research Design
The study used a descriptive, correlational type design with questionnaires and additional open-ended questions. This design allowed for examination of
relationships that potentially exist among and between study variables and facilitates the identification of such interrelationships. A descriptive design was also appropriate for identifying variables and describing demographic characteristics that may influence fall prevention services for older adult patients receiving care through
Tribal and urban Indian operated healthcare organizations. The mixed methods approach that incorporates both quantitative and qualitative methods offers a mechanism to “confirm or corroborate findings within a single study” (Grove, Burns,
& Grey, 2013, p.211).
Setting
The setting was 54 full service ambulatory healthcare clinics located within the California IHS service delivery area and funded by the federal government to provide health care services for members of federally recognized tribes. Of the
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approximately 41 Indian operated healthcare organizations operating within the CA
Area, several extend their services by operating satellite clinics, and eight are Urban
Indian operated. Appendix D displays a letter of support from the IHS/California
Area Office (IHS/CAO) leadership which permits the researcher to recruit study
participants from California Area IHS located Indian healthcare organizations by way
of IHS/CAO managed e-mail distribution lists. As noted in Chapter 1, “community-
based, ambulatory medical clinic” was defined as: A community-based, ambulatory
medical clinic is defined as an office-based health care setting where medical
services, including diagnosis, observation, consultation, treatment, intervention, and
referral services are rendered on an outpatient basis ("Ambulatory medical care,"
2003).
Population
The population for the study was licensed health care providers, occupying
various professional roles through their employment at Tribal and Urban Indian
managed healthcare organizations established to address the health care needs of
eligible American Indians/Alaska Natives through ambulatory clinic-based and
community health/outreach services. In fiscal year 2014, these health care providers
served the primary health care needs of approximately 92,583 AI/AN eligible active users (California Tribal Epidemiology Center, California Rural Indian Health Board,
2015, p. 89-90). Based on an informal query, it was anticipated the study population
would include approximately 300 licensed health care providers.
Sample
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The inclusion criterion was: Licensed Physician (MD and/or DO), Licensed
Registered Nurse (RN), Licensed Practical or Vocational Nurse (LPN or LVN),
Licensed Advanced Nurse Practitioner (NP), Licensed Public Health Nurse (PHN),
Licensed Pharmacist (RPH or Pharm D), Licensed Physicians’ Assistant (PA), or
Licensed Physical Therapist (PT) employed by California Area Tribal and Urban
Indian healthcare organizations. A survey respondent who associated with more than one of the aforementioned practice roles was asked to choose the one healthcare provider category that best reflected his or her current licensure and practice scope.
The exclusion criterion was: Survey respondents whose practice location was a “purchase and referred care” (PRC) only program. Respondents who identified with such practice locations were excluded from the study.
Power Analysis. A power analysis, through the use of an on-line software tool, was run using Pearson correlation coefficient statistic so as to determine an appropriate sample size for the current study (Hulley, Cummings, Browner, Grady, &
Newman, 2013). The Type II error was set at 0.20 before conducting the study so the statistic would have an 80% chance of detecting an effect if one actually exists
(Cohen, 1991). For a Type II error of .20, an expected r = .30, and an alpha of .05, a
minimum sample of 68 participants was indicated.
Definitions of Variables
Table 1 identifies each study concept/variable identified for the current study along with its’ corresponding theoretical definition, operational definition, and
measurement criteria.
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Table 1
Definitions of Study Variables and Associated Measurement Criteria
Variable Theoretical Definition Operational Definition Measurement Criteria
Health care provider (HCP) Health care provider refers to Health care provider, for the HCPs are the audience any individual, institution, or purpose of the current targeted to receive and agency that provides health research, is defined as an respond to the on-line survey services to healthcare employee of a tribal or questionnaire deployed consumers ("Health care Urban Indian healthcare through a survey link provider," n.d). organization who, by nature imbedded in a recruitment e- of his or her job, identifies mail. with one of the following practice roles: Licensed Registered Nurse (generalist), Licensed Vocational or Practical Nurse (LVN or LPN), Licensed Physician (MD and/or DO), Licensed Public Health Nurse (RN/PHN), Licensed Midlevel Practitioner (Advanced Nurse Practitioner or Physician Assistant), Licensed Pharmacist, or Licensed Physical Therapist.
Knowledge of best practices Individual health care Healthcare providers’ (Knowledge focused for preventing falls among providers’ general knowledge of recommended Questionnaire) Health care older adults knowledge of the following older adult fall prevention provider responses to on-line recommended older adult fall services will be measured survey questions specifically prevention practices: by self-reported responses targeted to collect data re of participants completing knowledge of older adult fall 1. individual fall risk survey items 7 - 11 of the prevention practices. assessment: a health care proposal-associated survey Descriptive statistics: professional, such as a doctor Measured by way of or nurse conducting an Percentages, Significant assessment of fall risk and P <. 05 (P = .05 is not then providing statistically significant) recommendations on avoiding falls,
2. strength and balance training: training in special exercises to build strength and improve balance,
3. home assessment and safety improvement: assessing and modifying the home or having someone come into the home to demonstrate ways to protect against falling,
4. medication review and management: having a professional (e.g., a physician or pharmacist)
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Variable Theoretical Definition Operational Definition Measurement Criteria
review medications that affect balance and help manage medications in order to prevent falls,
5. training in assistive device use: receiving special training from a physical therapist about how to use a cane or walker,
6. fall prevention education: receiving education that explains how to reduce fall likelihood.
Attitude toward best Individual health care Healthcare providers’ (Attitude focused practices for preventing falls providers’ attitude toward Questionnaire) among older adults attitude/perception as to the recommended older adult Health care provider degree of importance of each fall prevention services will responses to on-line survey of the following six be measured by self- items specifically targeted to recommended fall prevention reported responses of collect data about practices (refer to knowledge participants completing attitude/perceived variable for definitions): survey items 12, 13, 15, 16 importance of . and 17 recommended, older adult fall 1. individual fall assessment prevention practices. Descriptive statistics: 2. strength and balance Measured by way of training Percentages, Significant P < .05 (P = .05 is not 3. home assessment and statistically significant) safety improvement
4. medication review and management
5. training in assistive device use 6. fall prevention education
Provision of recommended A health care professional Healthcare providers’ (Practice focused services and referrals for working in a clinic or practice of recommended Questionnaire) preventing falls among older outreach setting, such as a older adult fall prevention Health care provider adults (Practice) doctor or nurse, conducts an services will be measured responses to on-line survey assessment of fall risk and by self-reported responses items specifically targeted to then provides and of participants completing collect data on practice of implements survey items 18 - 23 of the each, of six, older adult fall recommendations for proposal-associated survey prevention practices. avoiding falls – practice Descriptive statistics: based on AGS/BGS Measured by way of guideline recommendation Percentages, Significant P < and clinical decision making .05 (P = .05 is not statistically for older adult fall prevention significant) in terms of the following practices (refer to knowledge variable for definitions):
1. individual fall assessment
2. strength and balance training
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Variable Theoretical Definition Operational Definition Measurement Criteria
3. home assessment and safety improvement
4. medication review and management
5. training in assistive device use
6. fall prevention education
Barriers Reasons that respondent’s Barriers to recommended Qualitative – responses to service organization does not older adult fall prevention open-ended items of the provide recommended services were measured by survey instrument will be evidence-based fall way of self-reported categorized by fall prevention prevention services responses of participants best practice activity and completing survey items 24 discussed in narrative. - 26 of the associated survey instrument Closed-ended question (qualitative data) responses have been analyzed as nominal data (mode and frequency of distribution)
Respondent Characteristics: Demographic portion of survey has been addressed age, gender, practice role, and through items 1-6 practice setting) Age: As self-identified by HCP Age: 18 - 99 years Age of HCP: Chronological survey respondent (option to age in years not disclose has been included)
HCP Gender: Gender: As indicated by survey response to question Male, asking for self-identification as to gender. Female, or Other
Practice Role: Practice Role: (Questionnaire) Licensed Registered Nurse (RN/Generalist), Health care provider Licensed Public Health Nurse responses to on-line survey (RN/PHN), items specifically targeted to Licensed Practical/Vocational collect data re practice of Nurse, each, of six, older adult fall Licensed Physician, prevention practice Licensed Pharmacist, Licensed Advanced Nurse Practitioner, Licensed Physician’s Assistant or Licensed Pharmacist
Practice Setting: The practice setting (one) is selected by respondent Outreach/Community Health through on-line survey Department or response to either of two Ambulatory Medical Clinic available options.
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Measurement
Demographics. Demographics were measured by way of descriptive statistics; raw response data was analyzed using current version of IBM SPSS, SPSS v 25, to capture the following: measures of central tendency (mean, median, mode), and standard deviation (see Appendix E). The following demographic variables were used to describe the sample: age, gender, practice role, practice setting (clinic or community health/ outreach department), frequency of job-related contact with adults
65 years of age and over, and an awareness of others within their organization who work with older adults and are aware of policies/procedures. Because of the variation in services and ages of patients served by the health care providers and corresponding service organizations, and due to the study’s focus on KAPs associated with older adult falls, it was important to determine the frequency of providers job-related contact with individuals 65 years of age and older. Demographics of age and gender are understood to be essential to all types of research and so were considered, along with practice role and practice setting, as important for describing the sample and determining the study population for generalization of the findings (Grove et al.,
2013). Items numbered 1 - 6 of the survey instrument (see Appendix C), provided a mechanism for collecting demographic data for the current study.
Fall Prevention: Knowledge, Attitude, Practice and Barriers to Practice.
The “Senior Falls Key Informant” questionnaire (Laing et al., 2011) was adapted with permission from corresponding author (see Appendices B and C).
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According to Laing and colleagues (2011) study findings, three of the Fall
Prevention Practice items on their original survey instrument were evidenced to be
significant, null rejected, on the single pilot of the questionnaire. Consistent with the
evidence and with Laing et al.’s (2011) study survey content, the following six variables were considered under the heading of fall prevention practices: (1)
individual fall risk assessment; (2) strength and balance training; (3) home assessment
and safety improvement; (4) medication review and management; (5) training on assistive device; and (6) fall prevention education.
The survey was used to collect data with regard to the following four key study variables: (1) knowledge; (2) perceived importance (attitude); (3) provision of services and referrals (practice); and (4) barriers to providing FP services. One additional variable, practice setting, was added as it was useful for informing fall prevention approaches across clinic and outreach/community health settings. These key variable designations are easily cross-referenced with the survey instrument items
for accuracy of scoring, final data analysis and interpretation of findings. The final
survey instrument consisted of total of 25 open and closed-ended items. A matrix
(see Appendix E) depicts each of five research/study questions with its’
corresponding study variable, survey instrument item, and analysis statistic.
Procedure
Protection of Human Subjects. Since the IHS/CAO does not have a standing Institutional Review Board (IRB), IHS/CAO executive leadership provided a
“letter of support” (see Appendix D) which includes language that permits the
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researcher to use IHS/CAO maintained e-mail distribution lists of health care providers and CAIHS secure server for the purpose of recruiting study participants for the current study. The proposal was found to be exempt by the Case Western Reserve
University IRB and then was submitted to the National IHS IRB. Once a decision of exemption from the IHS IRB was received, the proposal was re-submitted to the Case
Western Reserve University IRB for final approval, and again found to be exempt.
Potential study participants were assured of the following: participation was voluntary, choice as to whether or not to participate would have no effect on their employment, no patient specific information was collected, and anonymity of response was ensured.
Recruitment. Following IRB approvals, an invitation to participate in the e- survey was delivered via e-mail distribution to the population of health care providers. Interested recipients were asked to click on a link to Qualtrics and required to first view the consent. If the individual agreed to participate, they clicked
“yes” and were taken to the survey. If the individual indicated “no” to the question, he or she were taken to the end of the survey and thanked for their interest.
The following process was used for on-line survey dissemination: potential respondents were afforded 14 work days to respond to the survey; the requested response date was included in the initial recruitment e-mail used for survey deployment and e-mail reminders referring the potential respondent back to the initial survey recruitment e-mail were provided; reminder e-mails were sent to potential respondents on the 5th and 10th days following the initial deployment of the survey
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(Dillman, Smyth, & Christian, 2009). According to the literature, there are no set
standards as to time allowed for survey response or as to the appropriateness and
timing of reminders. However, Dillman et al. (2009) suggest that researchers
carefully consider characteristics of the population being surveyed, sample size, study
topic, length of survey and resource limitations prior to making decisions with such
regard. Per a pre-test pilot of the survey instrument (see Appendix C) by a health care
professional colleague, completion of the survey, from beginning to end, took no
more than 15 minutes.
Data Management
The researcher retained control over raw response data. The Qualtrics survey was deployed from and responses housed on a firewall-secured server maintained by the California Area IHS; as permitted by letter of support from IHS/CAO (Appendix
D). A codebook which includes the following items was maintained by the researcher to ensure data were properly understood and interpreted: Assigned variable name, variable label, variable level of measurement, how the variable is recorded in the raw data, the variable’s units of measurement and for categorical variables, numeric codes along with what they represent. Qualtrics data were electronically exported to SPSS v 25 for analysis and were reviewed to identify and appropriately
act on missing and erroneous data. The SPSS v 25 Codebook function was used to
generate a copy of the associated document. Prior to analysis, data found to be
erroneous or meet the exclusion criterion were deleted and in the case of missing
responses, either imputed to reflect the mean or the case (respondent) removed. All
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such cleaning actions were consistent with widely accepted research actions meant to ensure accurate, unbiased statistical analysis results.
Data Analysis
Descriptive statistics. Descriptive statistics included measures of central tendency (mean, median, and mode), frequencies, ranges and standard deviations.
When feasible according to the survey response options and the number and distribution of responses, correlational statistics were used to describe the relationships between and among study variables per the group of participants.
Inferential statistics. Percentages were used to describe categorical data and, where feasible, Chi Square (χ2) statistics were computed in order to assess the significance of proportional differences. The study variables were described with means and standard deviations. Also, when feasible, relationships among and between the variables were measured using Pearson’s product moment correlational coefficient or in the case that the sample did not meet anticipated assumptions, a non- parametric correlation coefficient statistic such as Spearman’s rho was used. Unless otherwise noted, all reported differences found to be statistically significant were calculated at the 95 % confidence level, p < .05.
Internal consistency reliability. Cronbach alpha statistic, frequently used in research to estimate reliability/internal consistency reliability of a survey instrument, was run for the survey sub-scales for the following variables: Knowledge, Attitude, and Practice. Together these three sub-scales represent survey instrument questions 7
- 13 and 15 - 23. This process was important as some questions of the original survey
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were modified or eliminated in keeping with the intent of the current study. The literature suggests that every time a survey instrument is used, an analysis of the internal reliability consistency should be completed and reported (Bialocerkowski,
Klupp, & Bragge, 2010).
Analysis of open-ended survey items. Responses to the open-ended components of survey items 10 - 11 (knowledge-associated) and 25 (barrier- associated) were sorted, coded and grouped on their own. After that process the categories were compared to the literature and found to parallel the clinical practice guidelines representing one or more of the following six components considered essential to evidence-based, older adult fall prevention practice: (1) individual fall risk assessment; (2) strength and balance training; (3) home assessment and safety improvement; (4) medication review and management; (5) training on gait and assistive device use; and (6) fall prevention education (A Brief Guide to the Analysis of Open-Ended Survey Questions, n.d.).
Analysis of closed-ended survey items. The analysis of all closed-ended items was completed as identified in Appendix E.
Research Questions
Research Question 1. What is the relationship between health care providers’ knowledge (survey items 7-11) of and their attitude (survey items 12, 13,
15, 16, and 17) about providing evidence-based fall prevention services for older adults?
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Descriptive and inferential statistics were used. Measures of central tendency, frequency distribution, ranges and standard deviation were considered for describing the variables and correlational analysis, by way of Pearson Correlation Coefficient statistic, were used to identify associations or relationships between variables (see
Appendix E). Chi Square statistics were computed on individual knowledge- and attitude-associated survey instrument items so as to determine group differences or degree of association.
Research Question 2. What is the relationship between health care providers’ attitude (survey items 12, 13, 15, 16, and 17) about and their self-reported organizational practice (survey items 18 - 23) of evidence-based older adult fall prevention?
Descriptive and inferential statistics were used to answer this research question. Measures of central tendency, frequency distribution, ranges and standard deviation were considered for describing the variables and correlational analysis, by way of Pearson Correlation Coefficient statistic, were used to identify associations or relationships between variables (see Appendix E). Chi Square statistics were computed on individual attitude and practice subscale items of the survey instrument so as to determine group differences or degree of association.
Research Question 3. What is the relationship between health care providers’ knowledge (Survey items 7 - 11) of evidence-based older adult fall prevention and their practice setting (ambulatory clinic vs community health/public health/outreach department) (survey item 3)?
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Descriptive and inferential statistics were used to answer this research question. Measures of central tendency, frequency distribution, ranges and standard deviation have been considered for describing the variables and correlational analysis, by way of Pearson Correlation Coefficient statistic, were used to identify associations or relationships between variables (see Appendix E). Chi Square statistics were computed on individual knowledge- and practice setting-associated survey instrument items so as to determine group differences or degree of association. Responses to the open-ended portion of survey questions 10 and 11 were analyzed through the process described earlier in this chapter under subheading “analysis of open-ended survey questions” and will potentially offer further context.
Research Question 4. What is the relationship between health care providers’ knowledge (survey items 7 - 11) of and their practice (survey items 18 -
23) of evidence-based, older adult fall prevention?
Descriptive and inferential statistics were used to answer this research question. Measures of central tendency, frequency distribution, ranges and standard deviation were considered for describing the variables and correlational analysis, by way of Pearson Correlation Coefficient statistic, will be used to identify associations or relationships between variables (see Appendix E). Chi Square statistics were computed on individual knowledge- and practice-associated survey instrument items so as to determine group differences or degree of association. Responses to the open- ended portion of survey questions 10 and 11 were analyzed through the process
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described earlier in this chapter under subheading “analysis of open-ended survey questions” and will potentially offer further context.
Research Question 5. What do health care providers identify as barriers to providing recommended, evidence-based, older adult fall prevention services (survey items 24, 25, and 26)?
Descriptive statistics were used to answer this research question. Raw response data collected via Qualtrics survey were analyzed by SPSS version 25 to capture the following: measure of central tendency (mode), frequency, and chi square
(see Appendix E). Responses to the open-ended portion of survey question 25 were analyzed through the process described earlier.
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Chapter 4
Results
Purpose
The purpose of this research was to examine, within the context of tribal and
Urban Indian-operated health care services, health care providers’ knowledge of,
attitudes toward, and practice (KAP) of evidence-based older adult fall prevention
and the potential relationships that exist between and among these concepts.
Sample
An invitation to participate was sent to 233 health care providers. Twelve e-
mails bounced back; thus, the final population was 222 health care providers. A total
of 37 individuals consented to participate. Of these, two provided no additional
responses and two completed the introductory questions until redirected to end of
survey based on the study exclusion criterion. Thus, the final sample was N=33.
Please see Table 2 for description of the final sample as to practice roles, gender, age,
practice setting and contact with older adults.
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Table 2
Health Care Providers’ Characteristics
Characteristics Mean (SD) Median n (%)
Practice Role
Licensed Physician (MD or DO) 11 (33)
Licensed Pharmacist (RPH or Pharm D) 1 (3)
Licensed Advanced Nurse Practitioner 3 (9) (NP)
Licensed Physician’s Assistant (PA) N/A*
Licensed Registered Nurses (Generalist RN 18 (52) or PHN)
Licensed Practical or Vocational Nurse 1 (3) (LPN or LVN)
Gender Male 8 (24)
Female 25 (76)
Practice Setting
Community Health/Public 12 (36) Health/Outreach Department
Ambulatory Healthcare Clinic 21 (64)
Age in years (grouped) 51.5 (11.60) 53 n = 30
30 - 35 3 (10)
36 - 45 5 (17)
46 - 55 7 (23)
56 and older 15 (50)
Job Contact with Older Adults
Always 11 (33)
Often 17 (52)
Sometimes 5 (15)
Rarely 0 (0)
Not at all 0 (0)
Awareness of Others in their Organization with Job- related Contact with Older Adults and Knowledge of Organizations Policies/Procedures
Yes 33 (100)
* No respondents from these categories
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In regard to age, of the respondents who disclosed their age (N= 30), the range
was from 30 to 78 years, with a mean age of 51.5 years. Four individuals, those
meeting exclusion criteria (2) and those dropping out of the survey post providing
demographic data (2) were identified as members of the 25 years and younger age
group.
One other item of note is that a Chi Square analysis indicated a significant
association between health care providers’ age (by group) and knowledge item
“…..urgency of preventing falls in older” χ2 (6, N = 33) = 14.52, p < .05.
Knowledge
Respondents (N = 33) unanimously agreed that there were other staff within their organization who have contact with older adult patients as well as an understanding of organization’s programs and policies. When participants were asked to rate the urgency of preventing older adult falls while considering all problems/health issues faced by older adults aged 65 years and older, 48.5 % (n=16) of respondents indicated that fall prevention is “very urgent”, another 48.5 % identified fall prevention as “somewhat urgent”, and a much smaller percent (3 %) rated urgency of fall prevention for this population as “not very urgent”. When asked as to what extent older adult falls are preventable, 81.8 % of respondents indicated that falls are often preventable and the remainder identified such events as “always”
(6 %) or “sometimes” (12 %) preventable. When asked their about their individual knowledge or understanding of the prevention measures for reducing older adult falls,
33 % of respondents indicated “very knowledgeable”, 64 % identified with
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“somewhat knowledgeable”, and the remaining 3 % responded as “not very knowledgeable”.
For survey item 10, “the most important activity older adults can do for themselves to reduce their risk for falls”, 100 % (N = 33) responded. See Table 3 for the results of “best practice” activities for older adults fall prevention.
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Table 3
Most Important Activity that Older Adults Can do …to Reduce their Risk for Falls N = 33
Responses Categorized by Best Practice (BP) Activity Health Care Provider Response to Frequency of Responses by open-ended survey question BP Activity Category (frequency if > 1) n (%) N = 33
Strength & Balance Training Exercise (4) 11 (33)
Daily exercise
Regular exercise with balance training
Balance training
Practice Tai Chi (2)
Exercise – keep walking Home Assessment & Safety Improvement Plan ahead with walkers or other 13 (39) movement aides ready to use and a clear path open to most traveled areas/remove clutter (3)
Careful walking, use grab bars (2)
Know surroundings (2)
Home assessment for fall hazards..rugs, bathroom
Assess environment and fix any potential problems that could lead to tripping or falling (2)
Remove free throw rugs
Safety bars in bathroom
Reduce environmental risks Training for Gait & Assistive Device Use Use cane or walker 4 (12)
Gait, balance, strength transfer training (2)
Training that includes improved balance and transfer must be included as an optimum intervention strategy for preventing falls
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For item 11, “the most important thing community organizations such as theirs can do
to help “seniors” to reduce their risk for falls”, 97 % (n = 32) of participants offered a
comment; 3 % (n = 1) indicated “Don’t Know”. The responses were coded into
categories and then grouped on their own. The responses indicated a natural parallel
to the clinical practice guidelines for older adult fall prevention and so are displayed by “best practice” activities for older adult fall prevention (see Table 4).
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Table 4
Most Important activity that community organizations can do…..to help reduce older adult fall risk, N = 32
Responses Categorized by Best Practice (BP) Activity Health Care Provider Responses Responses by BP Activity Category n (%)
Individual Fall Risk Assessment Assess for fall Risk (3) 7 (21)
Assess risk factors at each visit
Fall screening
Screen for high fall risk
Screening
Strength & Balance Training Exercise 3 (9)
Provide exercise class
Provide exercise activity
Home Assessment & Safety Improvement Complete home risk assessment 8 (24)
Assess for clutter free environment, equipped with lighting, handrail, grab bars and nonslip mats
Home safety assessment
Identify home risks like loose rugs
Install safety bars in showers or bathrooms
Keep patient areas clear from clutter and well lit
Provide night lights and grab bars
Provide Handicapped ramps and walkways
Medication Review & Management Remind on side effects of meds 4 (12)
Decrease prescribing of high risk medications
Monitor patient medications that can contribute to falls
Training for Gait & Assistive Device Use Reminder for assess ADLs and 1 (3) assist with ordering aids as walkers, cane, sock assists/provide
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Responses Categorized by Best Practice (BP) Activity Health Care Provider Responses Responses by BP Activity Category n (%)
training
Fall Prevention Education Provide education with 9 (27) comprehensive fall prevention strategies
Establish a fall prevention program
Education
Training and Education with home visitation programs
Education and outreach
Discuss fall risks and prevention with person and significant other care persons
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Reliability of Survey Instrument
The Cronbach Alpha for the knowledge and attitude question portions of the
survey instrument indicated unacceptable and poor (.50, N = 5) internal reliability
respectively; however the Cronbach Alpha statistic associated with the organizational
practice question set (.74, N = 6) indicates an acceptable internal consistency
reliability for that question set.
Attitude /Perception
Given the reliability, we did not use the attitude perception summary score.
Table 5 displays results associated with individual FP Attitude and Practice study
variables. Of note is the result of a Pearson Correlation statistical analysis indicating
a statistically significant relationship between Attitude survey item “Individual Fall
Risk Assessment” and Knowledge item “Urgency of Preventing Falls in Older
Adults” r = .44, p = .001, p < .05, r2 = .19 (19 %).
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Table 5
Attitudes and practice of fall prevention services among community-based, tribal and Urban Indian operated organizations in California, N=33
Fall prevention Practice perceived Provision of Provision of Referral to outside Is not (FP) practice as very important service (practice) service (practice) organization(s) to involved in on a regular sometimes* provide service* providing or basis* referring for this service % Individual 94 27 46 24 3 assessment of fall risk Strength and 88 3 36 58 3 balance training Home assessment ____** 9 46 39 6 and safety improvement Review and 97 52 42 3 3 management of medication Training and use of 70 3 27 61 9 assistive devices Fall prevention 85 12 58 24 6 education
** Responses not captured.
* Practice/provision of services is identified in the last four columns of this table. Total service offered, by FP practice, is determined by summing the values in columns 3, 4 and 5 of each row of the table (e.g. for fall prevention education, 94 % of organizations represented address the Fall Prevention Education component of FP by offering it regularly, sometimes or by referring older adults to an outside provider (12 % + 58% + 24% = 94 %)
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Organizational Fall Prevention Practice
As aforementioned, Table 5 displays the results for survey items associated with the study variable FP Practice.
A Chi Square analysis indicates statistically significant (p < .05) associations between the following survey items with regard to practice of individual older adult fall prevention activities: Strength and Balance Training and “Home Assessment…..”
χ2 (9, N = 33) = 15.89, p = .019, p < .05, Cramer’s V = .50; Gait Training and
Strength and Balance training χ2 (9, N = 33) = 30.90, p = .000, p < .05, Cramer’s V =
.568; Gait Training and “Home Assessment….” χ2 (9, N = 33) = 24.40, p = .001, p <
.05, Cramer’s V = .623; Fall Prevention Education and Individual Fall Risk
Assessment χ2 (9, N = 33) = 28.10, p = .000, p < .05, Cramer’s V = .586; Individual
Fall Risk Assessment and “Home Assessment….” χ2 (9, N = 33) = 18.76, p = .016, p
< .05, Cramer’s V = .52
An analysis using Pearson’s correlation statistic was run on various survey instrument subscale items for practice to identify potential relationships between or among individual survey items; results are presented in Table 6.
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Table 6
Results of analysis using Pearson’s correlation statistic indicate significant relationship between the following pairs of “practice” subscale items
Paired R p value “practice” subscale items
Practice of “home r = .44 .009 assessment and modification” and practice of “strength and balance training”
Practice of r = .53 .002 “strength and balance exercise training” and practice of “gait training”
Practice of r = .66 .000 “individual fall risk assessment” and practice of “fall prevention education”
Practice of “home r = .59 .000 assessment and modification” and practice of “gait training”
Practice of “home r = .36 .036 assessment and modification” and practice of “fall prevention education”
Practice of “medication r = .37 .032 review and management” and practice of “gait training”
Practice of “medication r = .49 .004 review and management” and practice of “fall prevention education”
Practice of “gait
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Paired R p value “practice” subscale items training” and r = .37 .033 practice of “fall prevention education”
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Respondents indicated their organizations are involved in providing fall prevention education: provides service regularly (12 %), “provides service sometimes or some older adult clients” (58 %), “primarily refers service out to other individuals or organizations” (24 %), “is not involved” in providing service or referring (6 %).
An analysis, using Spearman’s correlation coefficient statistic, of the relationship between health care providers’ knowledge and their self-reported practice of older adult fall prevention suggests the frequency of health care providers’ job- related contact with older adults was significantly related to their extent of providing home assessment and improvements to home safety (rs =.38, p = .30, p < .05), frequency of health care providers’ job contact with older adults was significantly related to the extent with which their organization provided gait and balance training for older adults (rs = .47, p = .006, p < .01), and the health care providers’ extent of knowledge or understanding of the prevention measures for reducing falls among people 65 years of age and older is significantly related to the extent with which fall prevention education is provided by their organization (rs = .36, p = .040, p = .05).
Barriers to Older Adult Fall Prevention
Responses to survey item 24, (N = 33) (Table 7) indicated the following
“major reasons that older adults may not be participating in one or more of best practices in fall prevention activities”: Lack of transportation (4, 12 %), lack of availability of service in the community (5, 15 %), cost (1, 3 %), lack of awareness of service (20, 61 %), and cultural barriers (3, 9 %).
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Table 7
Responses to “major reason that older adults may not be participating in one or more, older adult fall prevention services” N = 33
Response Frequency %
Lack of 4 12 transportation
Lack of 5 15 availability of service in the community
Cost 1 3
Lack of Awareness 20 61 of service
Cultural barriers 3 9
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Survey item 25 had two parts, closed and open-ended. Participants were asked “whether there are reasons that an organization such as theirs may not be
providing one or more of the best practices for fall prevention”. Responses (N=33)
were: “Yes” (22, 67 %) and “No” (11, 33 %). Narrative comments for open-ended
portion of survey item 25 (see Table 8) were coded and then grouped by content into
categories which were then compared to the literature and found to parallel the
following five naturally-occurring categories often identified with barriers to
practice: 1) time limitations and competing priorities, 2) knowledge and skill deficits,
3) fragmentation and lack of coordination of services, 4) cost reimbursement, and 5) community resistance.
Sixty-one percent (20) of health care providers indicated that they were
“aware of other agencies or organizations in their community that they could partner with on older adult falls prevention efforts”; the remaining 39 % (13) indicated “no”.
When asked about whether they were “aware of other agencies or organizations for partnering”, 61 % (20) of health care providers answered “yes” and 39 % (13) responded “no”.
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Table 8
Why an organization may not be providing… best practices for preventing older adult falls
Categories Often Associated with Barriers to Older Adult Health Care Provider Response to Frequency of Responses by Fall Prevention Practice Open-ended Survey Question BP Activity Category n (%)
Busy practice 11 (33) Time Limitations/ Limited Staffing/ Competing Priorities Multiple priorities
Not a priority
Not enough time to do all good things in a visit
Overburdened primary care staff
Short staffed with multiple job responsibilities (2)
Smallest proportion of our patient population
Too much to do in an office visit
Too many other conditions to address
Need more Community Health Representatives (CHRs)
Provider knowledge/more 2 (6) Knowledge and Skill Deficits resource availability access needed given remote locations
Lack of organizational training and making this a higher priority
Dependent on provider referral 3 (9) Fragmentation and Lack of Coordination of Services Lack of participation
Lack of provider care
Practice refers to outside physical 3 (9) Cost Reimbursement Issues therapy since not have one on site
Limited resources (2)
Other Community Resistance 1 (3)
Total Responses 20 (61)
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Research Questions
Research Question 1. What is the relationship between health care
providers’ knowledge of and their attitude about providing evidence-based fall
prevention services for older adults?
It was not feasible to examine for relationships between survey instrument
subscales that represent health care providers’ knowledge and those that represent
their attitude. However, statistically significant associations were found between various individual knowledge and attitude survey items understood to be important to evidence-based older adult fall prevention.
The analysis suggests relationships between health care providers’ knowledge
as to the urgency of fall prevention services for older adults and their attitude with
regard to the importance of fall prevention education for helping to prevent older
adult falls (rs = .46, p = .006, p < .01), between their knowledge as to the most important thing a community organization can do to prevent older adult falls and their attitude as to the importance of individual assessment of fall risk factors with
recommendations for follow-up (rs = .70, p = .000, p < .01), between their
knowledge as to the most important action a community organization can take to
prevent older adult falls and their attitude as to the importance of fall prevention
education for preventing older adult falls (rs = .42, p = .015, p < .05), and between
their knowledge as to the urgency of fall prevention services to prevent older adult falls and their attitude as to the importance of individual assessment of fall risk factors with recommendations for follow-up (rs = .36, p = .042, p < .05).
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Research Question 2. What is the relationship between health care
providers’ attitude about and their self-reported organizational practice of evidence- based, older adult fall prevention?
It was not feasible to examine for relationships between survey instrument subscales that represent health care providers’ attitude and those that represent their organizational practice.
Research Question 3. What is the relationship between health care
providers’ knowledge of evidence-based older adult fall prevention and their practice
setting (ambulatory clinic vs community health/outreach)?
It was not feasible to examine for relationships between survey instrument
subscales that represent health care providers’ knowledge of evidence-based older
adult fall prevention and their practice setting.
Research Question 4. What is the relationship between health care
providers’ knowledge of and their self-reported organizational practice of evidence-
based, older adult fall prevention?
It was not feasible to examine for relationships between survey instrument
subscales that represent health care providers’ knowledge and their organizational
practice.
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A Pearson’s Correlation analysis was run on individual subscale items to identify correlations between or among individual survey items. Results suggest a statistically significant relationship between “Urgency of preventing falls in the older adult population” and “healthcare providers’ knowledge of older adult fall
prevention” r = .46, p = .006, p < .01, R2 = .22 (22 %). Spearman’s Rho statistic was
used to run a correlation analysis on this same pair of items with the following
results: rs = .41, p = .018, p < .05, R2 = .17 (17 %).
Research Question 5. What do health care providers identify as barriers to
providing recommended, evidence-based, older adult fall prevention services?
Research question 5 was addressed through survey items 24, 25, and 26. Most
respondents (61%) identified lack of awareness of service as the major reason that
older adults may not be participating in one or more of the best practices for fall
prevention. The remaining responses to this question were as follows in order of
ranking high to low: Lack of availability of service in the community (15 %), lack of
transportation (12 %), cultural barriers (9 %) and cost (3 %). In terms of the close-
ended responses to survey item 25, 11 (33 %) respondents indicated that there was no
reason why an organization such as theirs may not be providing one or more of the
best practices for older adult fall prevention. Twenty-two (67 %) respondents
indicated “yes” to survey item 25 and commented in the text box corresponding with
the open-ended portion of the survey question. Table 8 displays analysis results for
open-ended survey item 25. Survey item 26 invited response as to the respondents’
awareness of other agencies or organization in their community with which they
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could partner in terms of older adult fall prevention services; responses were as
follows: “yes” (61 %) and “no” (39 %).
Additional Statistical Analyses
In addition to the statistical analyses that were run in order to answer research
questions and describe the population, cross-tabulations and correlation statistics were
used to provide additional information about fall prevention knowledge by provider
type and the self-identified urgency of preventing falls in older adults. Respondents
who self-reported as being “very knowledgeable” about older adult falls also ranked
fall-risk identification as being of greater urgency (rs = .41, p = .018, p < .05).
Table 9 represents the results of an analysis using a cross tabulation statistic to
examine, by “practice setting”, healthcare providers’ expressed level of knowledge of
older adult fall prevention and their knowledge as to “urgency of preventing falls in
older adults”. An analysis using the same statistical technique was completed on demographic survey item practice role and knowledge item “.. describe your
knowledge or understanding of the prevention measures for reducing falls among
people 65 or older?” (see Table 10).
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Table 9
Responses to “….urgency of fall prevention in older adults” by health care provider’ “practice setting” N = 33
Urgency of Fall Prevention in Older Adults Current Practice Fall Prevention Fall Prevention Fall Prevention Total Setting “Very Urgent” “Somewhat “Not very urgent” Responses urgent” n (%) Community 8 (24) 4 (12) 0 12 (36) Health /Outreach Department Ambulatory 8 (24) 12 (36) 1 (3) 21 (64) Healthcare Clinic Total 16 (48) 16 (48) 1 (3) 33 (100)
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Table 10
Responses to “.. describe your knowledge or understanding of the prevention measures for reducing falls among people 65 or older” by self-identified “practice role” N = 33
Knowledge or Understanding of Older Adult Fall Prevention Measures Current Very Somewhat Not Very Not at Total Practice Role all Responses
n (%)
Licensed 3 (9) 7 (21) 1 (3) 0 11 (33) Physician (MD or DO)
Licensed 1 (3) 0 0 0 1 (3) Pharmacist (RPH or Pharm D)
Licensed 0 2 (6) 1 (3) 0 3 (9) Advanced Nurse Practitioner (NP)
Licensed 7 (21) 10 (30) 0 0 17 (52) Registered Nurse (RN) or Public Health Nurse (PHN)
Licensed 0 1 (3) 0 0 1 (3) Practical or Vocational Nurse (LPN or LVN) Total 11 (33) 20 (60) 2 (6) 0 33 (100)
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Chapter 5 Discussion
Introduction
The purpose of this study was to examine, within the context of tribal and
Urban Indian-operated health care services, health care providers’ knowledge of, attitudes toward, and practice (KAP) of evidence-based older adult fall prevention and the potential relationships that exist between and among these concepts.
Research Questions
Research Question 1. What is the relationship between health care providers’ knowledge of and their attitude about providing evidence-based fall prevention services for older adults?
It was not feasible to examine for relationships between survey instrument subscales that represent knowledge and those that represent attitude. The significant association between the perceived “...importance of individual fall risk assessment for older adults” and knowledge scale item “…urgency of preventing falls for adults ages
65 years and older” is of interest for understanding of the potential influence of attitude and knowledge on older adult fall prevention.
Based on the findings that individual fall risk assessment was perceived as
“very important” and fall prevention was rated as “urgent or somewhat urgent”, one might conclude that individual fall risk assessments would be provided regularly by the corresponding organizations. However, study findings indicated that individual fall risk assessments were not regularly or consistently provided by respondents’
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organizations. This is of concern since the scientific evidence widely considers “fall
assessment” a basic element of medical care for patients 65 years of age and older
(Gaboreau et. al., 2016) and emphasizes the practice of early fall-risk screening, along
with risk management, for its significant impact on reducing fall-risk, fall rate, and
injury or death from falls (Dionyssiotis, 2012; Renfro & Fehrer, 2011; Shubert et al.,
2013).
According to the open-ended responses as to barriers to fall prevention by
organizations, “lack of knowledge” of older adult fall prevention was not generally
identified as a barrier, although based on the closed-ended survey responses, most
respondents acknowledged being only “somewhat knowledgeable” as to measures for
reducing falls in older adults, that consistent with the study findings of Laing and
colleagues (2011). With regard to the potential discrepancy between closed and
open-ended responses in terms of HCPs’ knowledge of older falls prevention, further
study is needed. As the scientific literature indicates, there are many challenges to the multifactorial, complex process of older adult fall prevention, among which may be physicians’ lack of knowledge of fall-risk screening methods which may then lead to reliance on others for practice (Chou et al., 2006; Demons & Duncan, 2014). This may be one of the reasons for higher than anticipated frequency of with regard to some of the practice activities such as those of training for gait and balance aspects of
older adult fall prevention. Further examination and interpretation is needed with
regard to the reasons behind this knowledge-to-practice gap.
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Research Question 2. What is the relationship between health care
providers’ attitude about and their self-reported organizational practice of evidence- based older adult fall prevention?
It was not feasible to examine for relationships between survey instrument subscales that represent attitude and those that represent organizational practice.
A Chi Square statistical analysis for individual attitude and organizational practice, indicated significant associations between the following survey item pairs: attitude (perceived importance) towards “strength and balance training” and
“medication review and management”; importance of gait training and strength and balance training, importance of strength and balance training and older adult fall prevention education; importance of fall prevention education and strength and balance training; importance of strength and balance training and medication review and management; urgency of preventing older adult falls and importance of fall prevention education.
Medication review and management, individual fall risk assessment and strength and balance training were identified as “very important”; however important to note, in terms of organizations’ practice, most indicated “sometimes or for some patients” or “referred to other person/organization”. As an exception, just over one-
half of respondent’s indicated “medication review” was “regularly” provided by their corresponding organizations. Of concern was the finding that over fifty percent of responses indicated that organizations were providing “fall prevention education” only “sometimes and for some individuals” and 25% were “referring” the patients for
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this recommended fall prevention activity. These data indicate that health care providers regard each of five identified FP practices as “very important” and yet their organizations are not consistently, and routinely, providing these evidenced-based services for all older adult patients. This suggests that, for California Area healthcare organizations represented through the study, a gap between the evidence and fall prevention practice exists. And yet, we also know from study data (see Table 5) that health providers studied perceive evidence-based fall prevention to be important. This is very different from Gunderson and colleagues’ findings which identified physicians’ negativity towards older adults and raised the concern that such attitudes may negatively impact the care received (2005).
Research Question 3. What is the relationship between health care providers’ knowledge of evidence-based older adult fall prevention and their practice setting (ambulatory clinic vs community health/outreach)?
It was not feasible to examine for relationships between survey instrument subscales that represent “knowledge of evidence-based older adult fall prevention” and those which represent “practice setting”. Of the individual subscale items for knowledge and practice setting of those responding (N=33), a frequency distribution of responses indicates only one-third are “very knowledgeable” as to fall prevention, that a higher percentage of the overall respondents from “community health/outreach department” practice setting indicate fall prevention to be “very urgent” as compared to those responding to the same question yet are affiliated with the “clinic” setting, those who more frequently indicated fall prevention as “somewhat urgent” (see Table
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9). The community health/outreach practice setting staff traditionally focus on fall
risk factors such as “home environment assessment” since they have the opportunity to actually see the patient in their own living environment, however they are also very involved in “medication review” since visits frequently take place in the home where patients’ medications are readily accessible for review. Generally physicians, nurses,
pharmacists and mid-level practitioners are identified with the ambulatory clinic setting, which is the case in terms of the demographics for this study, thus in terms of
setting and practice role are uniquely positioned to provide individual risk
assessments, medication review and management. Future study on this particular
research question in terms of variations in practice setting is warranted and the
available data limits further interpretation. Such effort may have implications for
justification of funding and programs to appropriately and effectively address older
adult fall prevention.
Research Question 4. What is the relationship between health care
providers’ knowledge of and their self-reported organizational practice of evidence-
based, older adult fall prevention?
It was not feasible to examine for relationships between survey instrument
subscales that represent knowledge of evidence-based older adult fall prevention and
those which represent practice.
With regard to individual survey subscale items that pertain to knowledge and
practice, the findings indicate that all respondents rated their knowledge in one of the
higher response categories of “very” or “somewhat knowledgeable”, however most
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often the responses were identified with “somewhat knowledgeable”. The respondents unanimously (N = 33) indicated that there were others in their
organization who were aware of older adult fall prevention and resources which is
important for the purposes of carrying out this multifactorial, interprofessional effort.
The comments to the open ended knowledge questions provided a wealth of
information as to the current knowledge of the respondent in terms of limited resources for applying their knowledge and in some cases the indication for additional education on the topic. Although limited by small sample size, the findings suggest that, while there may be a need for additional knowledge, barriers to practice of older adult fall prevention are often the result of limited resources in terms of staff, funding priorities and fragmented organizational processes and the reason for inconsistently applied older adult fall prevention services.
Research Question 5. What do health care providers identify as barriers to
providing recommended, evidence-based, older adult fall prevention services?
Barriers to older adult fall prevention identified through the current study are
in line with those identified throughout the scientific literature. Study findings point
to lack of awareness as the major reason why patients may not be participating in one
or more older adult fall prevention services, whereas lack of availability of service in
the community, lack of transportation, cultural barriers and cost of service were less
frequently mentioned with such regard. The findings, in terms of why “organizations
may not be providing …best practices for preventing older adult falls” (see table 8),
indicated limitations of time, staffing, and competing priorities as reasons most
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frequently offered by HCP respondents; knowledge and skill deficits, fragmentation
of services, cost, and community resistance were identified to a lesser extent.
With the knowledge that older adult fall prevention is complicated, requires
interprofessional team effort and assessment skills to address the multifactorial
components, and that providers and their corresponding service organizations are
faced with competing priorities, it is not difficult to understand the slow rate of
progress toward a streamlined approach of ensuring regularly provided fall prevention
services that are consistent across organizations and practice settings. It is of concern that patients are frequently not aware of the service, or find that it is not available in the community. In this sense, patient education about older adult fall prevention and provider arrangements for collaboration or referral in cases where within-organization services not available is needed for ensuring patient awareness and continuity of evidence-based fall prevention services.
Methods
On a positive note, having access and authorization to use CAIHS e-mail distribution list for deployment of the study survey was a convenient way to reach the audience of providers who are known to be intimately involved in such work as older adult fall prevention, however on the negative side, maintaining the distribution lists for currency and accuracy is time intensive due to collection of information, documentation and frequent edits associated with high staff turnover. Another positive was that the method of survey was convenient, with limited communication
or travel required. On the other hand, utilizing e-mail for distribution and inviting
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participation led to concern as to whether invitations had arrived in the potential
respondents’ e-mail inbox during a time when the health care provider was on leave
or at a time when their schedules were so full that they had no time to participate.
The low response rate for the current study was cause for concern so for future study,
the researcher will consider other options and opportunities so as to ensure adequate
sample size for statistical “power”.
With regard to the survey instrument, the content of the original was
appropriate however the minor modification to the original, in terms of edits, may
have been responsible for the lower than acceptable reliability internal consistency of
two of the sub-scales. The change in method of survey deployment, e-mail as
opposed to telephone survey, may have been responsible for the small sample size.
Since a validated and reliable tool is essential to ensuring valid, reliable and
generalizable results this has been a lesson learned. For the amount of time and effort
that is required for conducting quality research, identifying and using an appropriate
survey instrument is of utmost importance in terms of findings and ability to make
inferences from them.
Theoretical Framework
The PARiHS framework, one of the first to focus on the explicit multi-
dimensional, complex nature of implementing evidence into practice, was identified
as, and has been an appropriate tool for guiding the focus of the current research project, interpretation of findings, and potentially, future work of integrating the evidence into older adult fall prevention for the CAIHS-based tribal and Urban Indian
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healthcare programs. The model represents the complexity of the process for moving
evidence into practice. Similarly, moving evidence into practice of older adult fall prevention is a complex process, requiring a multifactorial, interprofessional approach which requires consideration of “evidence”, “context” and facilitation” components and sub factors.
Use of this framework helped to ground the study and ensure the components of evidence, context, and facilitation were front and center from beginning of study, through stages of development, and then during interpretation of study findings. The concepts of evidence, context and facilitation, according to those who authored and others who later worked to enhance the PARiHS framework, may contribute to the process of introducing identified evidence into the practice setting (Harvey & Kitson,
2016; Kitson et al., 1998; Rycroft-Malone, 2004; Ullrich, Sahay, & Stetler, 2014).
For the current study, the elements of “evidence” and “organizational context” were defined as per the original PARiHS framework. The element of “evidence”, as per that framework, refers to research, clinical experience, patient preferences, and local information (Rycroft-Malone et al., 2004). The authors of the PARiHS framework proposed that when the components of evidence, context, and effective facilitation are high, the opportunity for integration of evidence into practice is also high (Kitson et al., 1998; Rycroft-Malone et al., 2002). In terms of the current study findings and in consideration of components suggested through the PARiHS framework to be important to integration of evidence into practice, the represented service organizations are not generally prepared to provide evidence-based fall
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prevention services regularly and for all patients ages 65 years and older. The study
suggests that factors associated with “evidence”, such as clinical practice and patient
preferences, and those identified with “context”, for example limited resources in
terms of funding, staffing, and provider education, may be hindering service
organizations’ ability to ensure full integration of evidence into older adult fall
prevention practice.
Study Limitations
A major limitation was that of a small sample size, that which determined the
power, limited the type of statistical processes that could be run in terms of analysis of data, and the ability to generalize the findings to the broader population. For this reason, the study findings may not be generalized to the broader population of service providers and or service organizations. Although a small sample, findings from the current study are believed to be important since this may be one of the first attempts to study health care provider knowledge, attitudes and organizational practice associated with care of AI/ANs in term of the geographic location, setting, health care provider sample, service organization and service population. The findings can be used as baseline to inform program development, and importantly, as a springboard for additional, more comprehensive research.
Another limitation was that of internal reliability and consistency of the survey instrument, a modified version of that initially used by Laing and colleagues to survey employees of senior serving organizations. The instrument did not meet
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satisfactory Alpha statistic for two of the variable subscales, thus raised concern over the instruments’ internal reliability and consistency.
The method of recruiting study participants and conducting the survey for the current study may have contributed to the small sample size. The researchers responsible for development and initial deployment of the original version of the survey instrument to query “employees of senior-serving organizations” conducted the survey by phone, rather than deploying the survey as an on-line survey as was the case for the current study. The authors of the earlier study also cited sample size as a limitation.
Respondents could potentially be representing the same organization through their responses since care was taken to ensure anonymity of study participants.
The researcher, in her role as area nurse consultant for the CAIHS, may have been known to study participants for the technical assistance and training she has provided on professional practice and healthcare-related issues, always in a non- supervisory capacity. Although the potential for bias of sample and response exists, the researcher took steps in advance of the study to ensure HCP anonymity and HCP awareness that the study was being conducted by researchers representing Case
Western University, Frances Payne Bolton School of Nursing.
Although the current study set out to examine relationships between and among key study variables, due to the small sample size and concerns over internal consistency reliability of survey instrument, the researcher was unable to use summary scale items for statistical analyses. This limited the researcher’s ability in
FALL PREVENTION SERVICES FOR OLDER ADULT, AMERICAN 109
terms of statistical analysis and making inferences to the larger population.
Frequency distributions, Chi Square, Spearman’s Rho, and Pearson’s Correlation statistics were used to identify frequencies and associations for examining the data and drawing conclusions about potential influences of knowledge, attitude, and/or practice of evidence-based, older adult fall prevention.
Implications and Recommendations
Implications for Future Research. In terms of implications for practice as well as future research, findings indicate a higher than anticipated practice of referring patients to outside service organizations for some of the services such as those associated with evidence-based older adult fall prevention, in association with
“strength and balance training” and “gait training” items. Future study to explore organizations’ reasons for referring for service and associated costs/benefits of referrals is warranted since “outside referrals” may both hinder the uptake of fall prevention services by older adults who may not see themselves at risk for falls and further deplete resources for under-resourced healthcare organizations.
That health care providers generally perceived evidenced-based fall prevention practices as “very important” and yet, with regard to practice, with the exception of medication review and management, services were offered by organizations on a “sometimes and with some older adults” basis which suggests a gap between perceived importance of evidence-base fall prevention and actual practice. Of possible explanations, the providers and their organizations leadership may at odds in terms of practice priorities or the providers ability to provide one or
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more of the evidence-based FP services regularly or for all patients may be limited by
one or more of the challenges expressed through the current study (see Table 7).
Since regular and consistent practice of all six components of evidenced- based FP is that recommended for the most effective fall prevention, the findings which indicate lower-than-optimal frequency across FP services in all but one category is of concern and implications for older adults, communities and health care organizations, this in terms of elevated financial burden across entities and diminished quality of life for older adults. Since attitude is known to play a major role in behavior, it is not clear as to why, in the case of this study, findings indicate inconsistencies between attitude/perception and practice in terms of positive attitude/ perception and lower-than-optimal frequency of regularly provided, evidence-based, older adult fall prevention services. The discrepancy calls for additional research, with potential respondents drawn from a similar provider population, so as to further
examine the inconsistencies between providers’ attitudes and their organizations’
practice.
The results from a Chi Square statistical analysis of health care provider age
(by group) and “…urgency of fall prevention for people 65 years of age and over”
(knowledge) were different than anticipated from the reviewed literature. Health care
providers who indicated that older adult fall prevention is “very urgent” were those
identified with younger age groups; those occupying the oldest age category, those 56
years of age and older, overwhelmingly identified fall prevention as being “somewhat
urgent”. Among the literature reviewed, Gunderson and colleagues (2005) have
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identified “ageism” for its’ potential influence on health care of older adults,
suggesting a negative impact of care from physicians or other care providers who
have negative attitudes toward older adults. From this, one might anticipate that older providers might have more interest or place higher importance on older adult fall prevention than those of younger age groups. Since, as Gunderson and colleagues
(2005) have suggested, physicians are often patients’ only source of health care and managers of their health care needs, future study to further explore the reason for the this unanticipated finding may help us to more clearly understand as to the potential influence of healthcare provider “age” and or “ageism” on practice or uptake of older adult fall prevention.
Inclusion of AI/AN older adult patients in the current study was not feasible
due to limited resources, those in terms of time and project funding. Therefore, a
survey of fall prevention knowledge, attitudes and practices of older adult AI/ANs
who receive care from California Area tribal and Urban Indian healthcare
organizations is recommended. Such research, would ensure important feedback
from older adult AI/AN users of services and, if conducted a face-to-face manner,
may facilitate patients’ engagement in and uptake of evidence-based fall prevention
activities, since as Ganz and colleagues (2008) suggested, face-to-face time with
patients is among various factors that can either hinder or promote fall prevention
services and their uptake. Both patient involvement and input, “evidence”, are
essential to ensuring “uptake” of fall prevention services (Ganz et al., 2008, p. 7;
Rycroft-Malone, 2004). Laing and colleagues (Laing et al., 2011) study was one of
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the few to survey of fall prevention practices of older adult patients as well as
provider organizations. More of this type of study is important to ensuring the
evidence needed for effective older adult fall prevention program development,
implementation and service uptake.
Implications for Practice, Health Policy, and Education. Findings from
the current study should be considered a small, yet important contribution to the
currently limited body of research evidence as to the influence of HCPs’ knowledge
and their attitude on the prevention of older adult falls, a significant public health
problem with costly consequences for older adults, their families and caregivers,
health care organizations and AI/AN communities in terms of financial burden,
diminished quality of life, and loss of productivity. These findings offer previously unavailable information that may be valuable for those individuals charged with
making local level decisions for grant proposals, funding prioritization and resource allocation.
Study findings provided important information as to relationships, or lack thereof, between study variables and also added to our understanding of the facilitators and barriers to practice of older adult fall prevention experienced by CA
Area Tribal and urban healthcare organizations and AI/ANs served . Childs and
colleagues have emphasized the importance of identifying factors that potentially
influence implementation of older adult fall prevention in order to successfully move
evidence into effective practice (Childs et al, 2012). With similar context,
Estabrooks et al. (2003) proposed that in order to increase research uptake by nurses
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it is necessary to understand what individual factors influence their research utilization behaviors. Although Estabrooks and colleagues specifically focused on factors that influence nurses’ research utilization behaviors, this same sentiment can be applied across HCP roles. And in terms of the current study, findings provide valuable information from HCPs as to barriers to fall prevention practice, those in terms of reasons why patients’ are not using FP services and those as to why organizations may not be providing one or more of the best practices for older adult fall prevention. That “lack awareness of fall prevention services” is identified as the most cited reason for low uptake by patients and that limitations in terms of time, staffing and competing priorities are identified as the major reasons that HCPs’ organizations are not offering FP services, offers evidence for organizational leadership to begin work to address the service gaps. These study findings, as well as those identified with earlier research, should be used to further develop local organizations’ practice capacity, policy development, staff education and community awareness.
In terms of implications for practice, study findings indicate a higher than anticipated practice of referring patients to outside service organizations for some of the services associated with evidence-based older adult fall prevention, particularly those of “strength and balance training” and “gait training” items. These findings may indicate that the service organization does not have adequate resources for providing the services on site, that health care providers do not have the practice
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skills and knowledge required or that such activity falls outside of organizations’ funding priorities.
For older adults, referrals can be burdensome, often requiring additional effort associated with making appointment arrangements, engaging caregivers and arranging for transportation, and becoming familiar with new “providers" and healthcare settings. Healthcare organizations attempting to provide evidence-based care, yet having limited resources, may see referral as their only available option.
With study findings in hand, organizations can should look at their fall prevention practices
Scientific, evidence-based older adult fall prevention guidelines and algorithms for implementation are widely available. As noted in Chapter 2, the AGS
/BGS Guidelines (2010) for older adult fall prevention are among the wide array of evidenced-based practice guidelines available and identified for use by health care providers working within the context of IHS, tribal and Urban Indian health care, and across practice settings. Current literature indicates that in order to effectively prevent older adult falls and subsequent fall-related injuries, health care organizations should adopt and integrate into practice the use of evidence-based, peer reviewed, clinical practice guidelines. Rubenstein and colleagues (2004) suggested adherence to practice guidelines for fall risk detection, evaluation, recommendations and treatment in order to improve outcomes in community-dwelling older adults. The integration of the practice of using such CPGs, with corresponding training for health care providers, may help to ensure consistency of process of providing fall prevention
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for older adults, while reducing challenges and barriers identified through study findings, those of limited staff, fragmented services, and knowledge deficit.
The findings may also inspire new ideas as to opportunities for prevention of injuries and with this regard, new ways to define roles and utilize staff, those who practice within clinic settings and those whose practice extends into community health departments/outreach settings. Such interprofessional, cross-practice setting collaboration aligns with current scientific literature which suggests that for effectively reducing older adult fall risk and associated injury, fall prevention efforts must take place across practice settings and practice roles (Noonan et al., 2011;
Tinetti, Gordon, Sogolow, Lapin, & Bradley, 2006). The findings from the current study may also have implications for re-defining practice of evidence-based, older adult fall prevention so that certain aspects of practice, those that do not require professional judgement and action by a health care professional, could be delegated to appropriately trained paraprofessionals, particularly those who work in outreach settings. Such would require including these paraprofessionals as members of the healthcare “team”, a decision that could expand the service organizations’ ability to consistently offer comprehensive, evidence-based older adult fall prevention services across practice settings and practice roles.
It is hoped that the findings from this study will be used to inform future fall prevention research, pre-professional nursing and interprofessional education within academic settings, community-based fall prevention program and policy development, provider continuing education, and quality improvement activities
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across healthcare settings and provider categories; the impact of which may result in
effective fall prevention practice, improved access to services, increased fall
prevention services uptake and subsequently, better patient health and quality of life
outcomes for older adult patients.
Conclusions
The findings from this research indicate statistically significant relationships
between responses to instrument subscale items identified with study variable
knowledge and those associated with attitude variable. No significant relationships
between and among full aggregate of survey items associated with attitude and
organizational practice, knowledge and organizational practice and/or knowledge
and practice setting were found. The majority of respondents perceive preventing
falls in individuals 65 years of age and older as “urgent” or “somewhat urgent”; while
most indicated that falls are “often preventable” as opposed to “always preventable”.
Only one-third of respondents indicated “very knowledgeable” as compared to
the two-thirds who responded to being “somewhat knowledgeable”, both responses in
terms of older adult fall prevention. Such findings suggests that provider education
may be warranted.
The fall prevention activities “medication review and management”,
“individual fall risk assessment” and “strength and balance training” were all three identified as “very important” by HCPs; however, the services were often provided
by “referral” to outside individuals or organizations or “provided sometimes or for
some individuals”. Just over half of respondents indicated that “medication review”
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is provided “regularly” by their organizations. Of major concern are the findings that
medication review and management, individual fall-risk identification, and fall prevention education are not provided (by way of practice or referral) on a regular, annual or otherwise, basis for all patients ages 65 years and older. Although a survey of older adult AI/AN users of services, for their input, was outside the limits of the current study, the research literature prompts us to understand that medication review and management is a recommended “best practice” for older adult fall-risk reduction
(American Geriatrics Society/British Geriatrics Society, 2010). As Dionyssiotis
(2012) has indicated through his study, multifactorial fall prevention programs are recommended over approaches that single out medication review and management.
As was found from the current research, practice was not in line with that evidenced to lead to fall risk reduction and fall prevention in the older adult population, one considered to be at elevated risk based on prevalence of chronic disease and associated elevated rates of medication use. With regard to the current study, responses indicate that a multifactorial approach to older adult AI/AN fall prevention is not occurring, one that is warranted based on this at risk service population. When fragmented approaches occur, the results of intervention are not known to be as effective in producing improved patient outcomes.
Study findings suggest a gap between attitude and practice; limited knowledge about fall prevention; organizational priorities that frequently do not include older
adult fall prevention; limited fall prevention resources; organizations that focus on
one or two fall prevention activities, rather than act in a comprehensive practice (all
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six recommended areas of activity) and levels of knowledge and practice of older
adult fall prevention that vary by practice setting and health care provider role.
Tribal and Urban Indian healthcare organizations that consistently incorporate an interprofessional and multifactorial approach to older adult fall prevention, ensure continuing education of fall prevention for health care providers, ensure organizational resources and prioritization of fall prevention services, and encourage use of clinical practice guidelines/algorithms to streamline practice will ensure evidence-based, older adult fall prevention services for AI/ANs served. The process of integrating evidence-base guidelines into practice of older adult fall prevention is complex and full implementation, challenging. However, evidence-based, older adult fall prevention is widely recognized for its’ role in effectively reducing fall risk and fall-related injuries, with consequences of improved quality of life and health outcomes for older adult AI/ANs and decreased financial burden for older adult patients and their healthcare organizations.
Findings from this study will be shared broadly with service organizations’ administration, nurses and other health care providers identified for their important roles related to closing the evidence to practice gap related to older adult fall prevention for AI/ANs. Since dissemination of findings is an important aspect of the research process, the researcher plans to communicate current study findings through presentations and eventually, a manuscript for publication. Broad dissemination of these study finding will enhance the awareness of a wide readership of heath care professionals who have the opportunity to work interprofessionally and across
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practice settings to engage in and influence the practice of older adult fall prevention.
It is through interprofessional collaboration, leadership engagement, clinic-
community health care linkages, prioritization of resources and consideration of the
important interplay of evidence, context, and facilitation that evidence-to-practice gaps for older adult falls prevention can be narrowed.
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Appendix A
Algorithm: Fall Risk Assessment (American Geriatrics Society/British Geriatrics Society, 2010)
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Appendix B
Permission to use Laing and Colleagues’ Survey Instruments for Research Study
From: Sharon Laing
Hello Susan--
Please find attached, both instruments -- best wishes on your study.
Sharon Laing
On Mon, Feb 16, 2015 at 2:28 PM, Susan Ducore
I am a doctoral student at Case Western Reserve University, Frances Payne Bolton School of Nursing. My research interest is in line with your 2011 article published in Journal of Aging Research, that entitled "Fall Prevention Knowledge, Attitude, and Practices of Community Stakeholders and Older Adults". I am interested in replicating your work in part, focusing on services offered to American Indians/Alaska Natives through ambulatory care-based Tribal health organizations. Would it be possible to obtain a copy of the tools used /referenced in your related article for such purpose? More specifically I am hoping for access to both the employee and older adult questionnaires. As you and your colleagues have suggested, little is known with regard to this area of research. You have also mentioned in your article, as a study limitation, that survey items had not been pilot- tested prior to your research. Data obtained through a replication of this study, yet with a different cohort of patients and providers, would once again test the tools re reliability and validity. And, resulting findings would provide an important contribution to a currently-limited body of research and offer important information to be used as a basis for future provider and patient education.
Please let me know, as soon as possible, as to if and how I might obtain permission to access the two survey questionnaires for use in my upcoming research related to falls prevention.
Thank you.
Sincerely,
Susan [email protected]
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Appendix C Older Adult Falls: Knowledge, Attitude and Practice Study
As you complete the following survey, please select the answer that most accurately reflects your current knowledge, opinion, and practice of older adult fall prevention.
01: Which of the following job categories best describes your current practice role/position as an employee of a California Area Tribal Healthcare Organization? (Select 1 answer)
___Licensed Physician (MD or DO) ___Licensed Pharmacist (RPH or Pharm D) ___Licensed Nurse Practitioner (NP) ___Licensed Physician’s Assistant (PA) ___Licensed Registered Nurse (RN or PHN) ___Licensed Practical or Vocational Nurse (LPN or LVN) ___Licensed Physical Therapist (PT)
02: Which one of the following best describes your Gender? (Select 1 answer)
___Male ___Female ___Other
03: Which one of the following most accurately describes the practice setting where most of your healthcare services are provided?
___Community Health/Public Health/Outreach Department ___Ambulatory Healthcare Clinic ___Purchase and Referred Care (only)
04: What is your current age in years?
___ (age in years) ___Prefer not to answer
05: How often does your job involve contact with older adults, those 65 years of age and older? (Select 1 answer)
___Always ___Often ___Sometimes ___Rarely ___Not at all
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06: Are there other staff within your organization who have contact with older adult patients as well as an understanding of your organization’s programs and policies? (Select 1 answer)
___Yes ___No
07: Considering all of the health-related issues or problems facing people 65 years of age and over, how would you rate the urgency to prevent falls in older adults? (Select 1 answer)
___Very urgent ___Somewhat urgent ___Not very urgent ___Nor at all urgent
08: To what extent are falls among older adults are preventable? (Select 1 answer)
___Always ___Often ___Sometimes ___Rarely ___Never
9: How would you describe your knowledge or understanding of the prevention measures for reducing falls among people 65 or older? (Select 1 answer)
___Very knowledgeable ___Somewhat knowledgeable ___Not very knowledgeable ___Not at all knowledgeable
10: What is the most important activity that older adults can do for themselves to reduce their risk for falls? (Select 1 answer)
___Identify one activity. ___Don't know
11:
What is the most important thing that community organizations such as yours can do for seniors to help reduce their risk for falls? (Select 1 answer)
___Identify one action . ___Don't know
This next set of questions covers six activities that may be considered best practices for helping to prevent falls among older adults. For each of the following six practices, please select the answer that best represents how important you think it is in helping prevent falls among older adults.
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12: How important is the following practice in helping prevent falls among older adults: Individual Assessment of Fall Risk Factors, with Recommendations for Follow-Up? (Select 1 answer)
___Very important ___Somewhat important ___Not very important ___Not at all important
13: How important is the following practice is in helping prevent falls among older adults: Strength and Balance Exercises? (Select 1 answer)
___Very important. ___Somewhat important ___Not very important ___Not at all important
14: How important is the following practice in helping to prevent falls among older adults: Home Assessment and Improvement to Home Safety?
___Very important ___Somewhat important ___Not very important ___Not at all important
15: How important is the following practice in helping prevent falls among older adults: Review and Management of Medications that Affect Balance? (Select 1 answer)
___Very important ___Somewhat important ___Not very important ___Not at all important
16: How important is the following practice in helping prevent falls among older adults: Gait Training and Training on the Use of Assistive Devices (For Example: Canes and Walkers)? (Select 1 answer)
___Very important ___Somewhat important ___Not very ___Not at all important
17: How important is the following practice is in helping prevent falls among older adults: Fall Prevention Education? (Select 1 answer)
___Very important ___Somewhat important ___Not very important ___Not at all important
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The next few questions will help us to better understand your organization's involvement in providing fall prevention associated best practices for older adults, either directly, through referral to other organizations, or not at all.
18: To what extent does your organization provide..... Individual Assessment of Fall Risk Factors, with Recommendations for Follow Up? (Select 1 answer) ___Provides this service regularly to most seniors ___Provides this service only sometimes or only with some clients ___Primarily refer seniors to some other person or organization for this service ___Is not involved in providing or referring seniors for this service
19: To what extent does your organization provide...... Strength and Balance Exercises? (Select 1 answer)
___Provides this service regularly to most older adults ___Provides this service only sometimes or only with some clients ___Primarily refer older adults to some other person/organization for this service ___Is not involved In providing or referring seniors for this service
20: To what extent does your organization provide...... Home Assessment and Improvements to Home Safety? (Select 1 answer)
___Provides this service regularly to most seniors ___Provides this service only sometimes or only with some clients ___Primarily refer older adults to some other person or organization for this service ___Is not involved in providing or referring seniors for this service
21: To what extent does your organization provide... Review and Management of Medications that Affect Balance? (Select 1 answer)
___Provides this service regularly to most seniors ___Provides this service only sometimes or only with some clients ___Primarily refer older adults to some other person/organization for this service ___Is not involved in providing or referring seniors for this service
22: To what extent does your organization provide...... Gait Training and Training on the Use of Assistive Devices, such as canes & walkers? (Select 1 answer)
___Provides this service regularly to most seniors ___Provides this service only sometimes or only with some clients ___Primarily refer seniors to some other person or organization for this service ___Does not provide or refer seniors for this service
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23: To what extent does your organization provide...... Fall Prevention Education? (Select 1 answer)
___Provides this service regularly to most older adults ___Provides this service only sometimes or only with some clients ___Primarily refer older adults to some other person or organization for this service ___Is not involved in providing or referring seniors for this service
24: Which of the following is the major reason that older adults may not be participating in one or more of the best practices associated with preventing older adult falls?.. (Select 1 answer)
___Transportation ___Lack of availability of service in the community ___Cost ___Lack of awareness of service ___Cultural barriers
25: Are there reasons that organizations such as yours may not be providing one or more of the best practices related to preventing falls? If yes, name one reason. (Select 1 answer)
___Yes (please state one reason) ___No
26: Are you aware of other agencies or organizations that you could partner with to promote older adult falls prevention in your community? (Select 1 answer)
___Yes ___No
Thank you very much for your time and cooperation in completing the survey. If you are interested in entering a drawing for a chance to receive one of four $25 Starbucks gift certificates, please click on the following link that will take you outside of the survey to an independent website for drawing entry instructions (link to be inserted here)
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Appendix D
Letter of Support from Indian Health Service/California Area Office
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Appendix E
Matrix: Research Questions/Study Variables/Survey Items/Analysis Statistic and Method
Research Questions Study Variables/Demographic Research Questions Analysis Statistic and Method (Q1-Q5) Variables /associated Survey Items 1-26
Q1. What is the Research Q1 considers potential Research Q1: For Research Q1, Q2, Q3, and relationship between relationships between study HCP Knowledge Q4 the following applies: health care providers’ variables “HCP Knowledge” of component will be knowledge of and their evidence based older adult falls addressed through Survey HCP Response data will be attitude about prevention and “HCP Attitude” items 7-11 and HCP collected by way of on-line providing evidence- about practice-related services for Attitude component survey instrument using based fall prevention older adult fall prevention through Survey items 12, Qualtrics. services for older 13, 15, 16, and 17 adults? Raw data will be analyzed through SPSS using descriptive Q2. What is the Research Q2 considers potential Research Q2: and inferential statistics as relationship between relationships between study HCP Attitude component follows: healthcare providers’ variables “HCP Attitude” about will be addressed through attitude about practice-related services for older Survey items 12, 13, 15, Descriptive Statistics - Mean, evidence-based, adult fall prevention and “HCP 16, 17 and HCP Practice median, mode, frequencies, practice-related Practice” component, through ranges, and Standard Deviations services for older adult Survey items 18 - 23 will be analyzed by way of SPSS fall prevention and their self-reported practice of evidence- Spearman’s Rho (non- based, older adult fall parametric) and Pearson’s prevention? (Parametric) correlation coefficient were considered for Q3. What is the Research Q3 considers potential Research Q3: use as test for relationships relationship between relationships between study HCP Knowledge between study variables: HCP healthcare providers’ variables “HCP Knowledge” and component will be Knowledge and HCP Attitude, knowledge of “HCP Practice Setting” addressed through Survey HCP Attitude and Practice, HCP evidence-based, older items 7-11, and HCP Knowledge and practice setting, adult fall prevention Practice Setting and HCP Knowledge and and their practice component, through Practice; setting (ambulatory Survey Item 3 clinic vs community Chi Square statistic was run to health/outreach)? determine associations / differences statistical significance Q4. What is the Research Q4 considers potential Research Q4: between variables (see variable relationship between relationships between study HCP Knowledge sets identified above) healthcare providers’ variables “HCP Knowledge” component will be knowledge of and “HCP Practice” addressed through Survey Significant P < 0.05 (P = 0.05 is evidence-based, Items 7-11 and HCP not statistically significant) practice-related Practice component, services for older adult through Survey Items 18- Cronbach alpha statistic will be fall prevention and 23 run to estimate reliability/internal their self-reported consistency reliability of the practice of older adult three question scales associated fall prevention? with the primary study variables, inclusive of survey items 7 – 13 Q5. What do healthcare Research Q5 considers the study Research Q5: and 15 – 23. providers identify as variable “Barriers” to providing Barrier barriers to providing recommended evidence-based, variable/component will For Research Q 5 the following recommended, older adult fall prevention be addressed through measurement and data analysis evidence-based, older services Survey items 24 - 26
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adult fall prevention applies: services? Appendix E HCP Response data will be (continued) collected by way of on-line survey instrument using Demographic Demographic Qualtrics. characteristics for characteristics: Survey describing the sample items 1-6. Descriptive Raw data will be analyzed by will be collected statistics will be run current version of SPSS to through Survey items through SPSS on this data capture the following: measure of 1 - 6. for use only in describing central tendency (mode) and the study sample (with the frequency and Chi Square. Open- following exception: ended response data will be Survey item 3 will collect sorted into naturally-occurring data for analysis re categories for analysis and Research Q 3) interpretation.
Descriptive statistics: Measured by way of percentages, Significant P < 0.05 (P = 0.05 is not statistically significant)
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Appendix F
E-mail Invitation to Participate in Survey From: Susan E. Ducore Sent: Date (October 3, 2017) To: Health Care Provider Distribution List Member Subject: Survey of CA Area Indian Health Program-Based Health Care Providers
Dear Health Care Provider,
I am writing to ask for your participation in a survey that I am conducting in conjunction with Case Western Reserve University, Frances Payne Bolton School of Nursing. I am asking health care professionals like you to participate in a study of factors that may influence the integration of Best Practice into older adult fall prevention services for American Indians/Alaska Natives eligible to receive care through federally funded Tribal and urban Indian healthcare organizations located within the California Area, Indian Health Service. Your responses to this survey are very important and will help in advancing older adult fall prevention related healthcare services, provider education, and research. The survey will be open for your response for two weeks, 14 work days and will close on October 24. This is a short survey and should take you no more than 15 minutes to complete. Please click on the link below to go to the survey website (or copy and paste the survey link into your Internet browser to begin the survey).
Survey Link: (link imbedded here)
Your participation in this survey is entirely voluntary and your responses anonymous to the researcher and others involved. As such, no personally identifiable information will be associated with your responses in any reports of this data.
I appreciate your time and consideration in completing the survey. It is only through the assistance of health care providers like you that we can gather information to help us to better understand factors that influence practice gaps so that we may direct future efforts to ensure the best possible resources for AI/ANs eligible to receive health care through IHS-funded Indian health care organizations.
Many thanks, Susan E. Ducore DNP Student Case Western Reserve University Frances Payne Bolton School of Nursing