Person-environment interactions contributing to nursing home resident falls

Effect of the Physical Environment on Health and Well-Being of Nursing Homes Residents: A Scoping Review

OBJECTIVES

In what way the physical environment of nursing homes (NHs) influences the health and well-being of nursing residents is not well codified. The authors aimed to review scientifically based knowledge on this topic.

DESIGN

A systematic scoping review of research into the effect that physical environment in nursing homes has on residents' health.

SETTING AND PARTICIPANTS

Search for relevant English-language articles in PubMed and the Cochrane database before April 15, 2022. Article selection and data extraction were performed by 2 researchers. Studies were included if conducted on nursing home residents and if they examined associations between components of the physical environment and health outcomes.

MEASURES

The review was performed in accordance with the PRISMA statement.

RESULTS

Of 1347 articles retrieved, 59 met the inclusion criteria-40 observational, 1 survey, and 18 interventional studies, of which 5 were randomized controlled trials. Certain environmental features repeatedly show significant positive effect on resident's health, such as noise reduction, tuning of lighting, natural light, easy access to garden, dining environment, and resident-centered interior renovation. Nursing home size was not found to have a direct relationship to resident health and well-being, although it is related to more than only the physical environment (eg, social environment).

CONCLUSIONS AND IMPLICATIONS

This review provides guidance in selective areas of the physical environment for the design of nursing homes, with potential benefits for the health and well-being of residents.

Environmental hazards increase the fall risk among residents of long-term care facilities: a prospective study in Shanghai, China

BACKGROUND

Falls are one of the most common safety concerns in long-term care facilities (LTCFs).

OBJECTIVE

To evaluate the associations between the environmental hazards and the fall risk in LTCF residents.

DESIGN

Prospective study with 12-month follow-up.

SETTING

Twenty-five LTCFs in a central district of Shanghai.

SUBJECTS

A total of 739 older people participated and 605 were followed up for 1 year.

METHODS

Environmental hazards were measured using a 75-item Environment Assessment Checklist, and the associations between environmental hazards and falls were analysed using univariate and multilevel logistic regressions.

RESULTS

The incidence of falls was 0.291 per person with 11 items/LTCF of hazards on average. The most common hazard items were inadequate/inappropriate handrails (96% LTCFs; odds ratio (OR) for falls: 1.88 [95% confidence interval: 1.13-3.13]), unsafe floors (92% LTCFs; 2.50 [1.11-5.61]) and poor lighting (84% LTCFs; 2.01 [1.10-3.66]). Environmental hazards were most frequently distributed in bedrooms (96% LTCFs), shared toilets/showers (80% LTCFs) and individual toilets/showers (68%LTCFs) and accounted for 20% of the differences in falls occurrence among the LTCFs. After adjusting for individual intrinsic and fall-related behavioural factors, it is found that having more than eight environmental hazard items increased the fall risk among older residents (adjusted OR = 4.01 [1.37-11.73]). Environmental hazards and toilet visits at night showed significant associations with falls (adjusted OR = 5.97 [1.10-32.29]).

CONCLUSIONS

The high prevalence of environmental hazards associated with falls highlights the urgency of improving environmental safety in LTCFs and the need of environmental safety policies, resource allocation and interventions in falls prevention.

Managing and keeping control: A qualitative synthesis of nursing and care staff strategies to prevent older people from falling

AIM

To better understand formal care providers' role in fall prevention.

DESIGN

Qualitative synthesis as part of an integrative review.

DATA SOURCES

Fifteen electronic databases were consulted with the time limit being December 2017. Studies included were qualitative primary studies on formal care providers and fall prevention of people over 65 years of age in health care facilities. 17 studies were included.

REVIEW METHODS

Qualitative researchers carried out a critical appraisal and abstraction of the studies retained. Primary studies were imported into Nvivo 12 software; grounded theory procedures of constant comparison, microanalysis, coding, development of memos and diagrams were completed concurrently in a continuous growing process of data conceptualization. Analysis was iterative; it started with open coding and ended with the development of an integrative memo.

FINDINGS

Primary studies were synthesized with the emerging core category of "Managing and keeping control" and described by the emerging strategies of risk management, risk control and articulation work. These three categories account for the formal care providers' role in fall prevention in health care facilities.

CONCLUSION

Fall prevention is not given by a series of means and instruments; it is rather built in the interactions between formal care providers and the material and social world. The interactive character of prevention implies that outcomes cannot always be anticipated.

IMPACT

Although falls are one of the most researched clinical problems in nursing, the role played by nursing and care staff is dispersed and scantily documented. Formal care providers alternate risk management with risk control strategies to prevent older people from falling in health care facilities, they also resort to the articulation of the health care team as a complementary strategy. This review shows the dynamic character of fall prevention, which is something that has tended to go unnoticed in the literature and in policy.

Evaluation of care staff knowledge, confidence, motivation and opportunity for preventing falls in residential aged care settings: A cross-sectional survey

AIMS

To explore care staff knowledge about falls and confidence, motivation and opportunity to undertake fall prevention strategies, in residential aged care (RAC) along with preferences for fall prevention education.

BACKGROUND

Falls account for the majority of adverse clinical events in RAC settings. Care staff in RAC settings are in a key position to influence residents' actions to prevent falls, provided they have the necessary knowledge and skills.

METHODS

A cross-sectional survey design with a purposive sample of 147 care staff at eight RAC facilities was undertaken in 2015. A custom-designed questionnaire examining knowledge, confidence, motivation and opportunity to undertake falls prevention strategies was used.

RESULTS

Only 39 (26.5%) care staff were aware that the residents they cared for were at high risk of falls. Care staff knowledge of intrinsic falls risk factors was very limited, for example, only 18 (13.53%) observed for side effects of medication and just four (1.04%) were aware of continence issues. Conflicting duties also limited care staff time to undertake falls prevention strategies. Preferences for falls prevention education indicated face-to-face interactive discussions in the workplace (n = 98, [66.7%]) with reminder posters displayed around the facility (n = 80, [70.8%]).

CONCLUSIONS

Residential aged care organisations need to engage with care staff to provide tailored falls education incorporating learning preferences and targeting knowledge gaps, to improve awareness of intrinsic risk factor impact and uptake of evidence-based prevention strategies. Despite care staff being highly motivated, they have limited opportunity to assist residents with fall prevention within their workload. RAC management and funding bodies must address opportunity for care staff to fulfil this crucial role to benefit resident safety.

IMPLICATION FOR PRACTICE

This study identified gaps in care staffs' knowledge and skills in undertaking falls prevention strategies in residential aged care settings. These findings will assist residential aged care organisations and health professional educators to design evidence-based falls prevention education tailored to their care staffs' needs and preferences to facilitate adoption.

What Factors Predict Falls in Older Adults Living in Nursing Homes: A Pilot Study

BACKGROUND

In community-dwelling older adults, slow gait speed is linked to falls; however, little is known about the use of gait speed to predict falls in nursing home residents. The prevalence of risk factors for falls in nursing home residents is multifactorial.

OBJECTIVE

The purpose of this study was to examine the relationship between falls and multiple factors such as age, sex, gait speed, mobility device, fear of falling, cognitive function, medication, and environmental causes in a nursing home setting.

MATERIAL AND METHODS

Participants were recruited from a nursing home. Independent variables such as age, sex, gait speed for 40 feet, use of a mobility device, fear of falls, cognitive function, medication, and environmental causes of falls were measured and recorded. The dependent variable was falls. Participants were followed-up for a period of six months for falls. Falls were documented from the computerized medical records at the facility.

RESULTS

Five of the 16 participants had falls in the follow-up period. Exact logistic regression, bivariate analysis, showed no significant relationship between falls and the independent variables of age, sex, gait speed, mobility device, fear of falls, cognitive function, and medication. More than 30% of recorded falls had an environmental cause, which was significant at p = 0.0005.

CONCLUSION

Environmental causes had a significant relationship with falls in nursing home participants. Environment hazard monitoring is therefore important to ensure the safety of nursing home residents.

Connection between competence, usability, environment and risk of falls in elderly adults

Objective:

to determine connections between competence, usability, environment and risk of falls in elderly adults.

Method:

correlational descriptive study, 123 elderly adults, both male and female, aged 70 years and older were included. Data was collected via the Tinetti Scale, CESD-7 Scale, Montreal Cognitive Assessment, Usability Questionnaire on Housing and Housing Enabler; and sociodemographic and health background certificate data. For data analysis, descriptive and inferential statistics were used, multivariate linear and logistic regression models were adjusted.

Results:

42.0% of the elderly adults had presented with falls, with a higher prevalence in women, and in the group of 70-75 years. The physical environment of the house, gait, and usability were set as risk factors for falls. A negative relationship between usability and depressive symptoms, cognitive health, balance, gait, the social and physical environment was found, p <0.05; and a strong positive correlation between walking and balance, p <0.05.

Conclusion:

this study helps to better understand the phenomenon of falling, to find a connection between usability with the risk of falls, and other variables.

Prevalence of household falls in long-lived adults and association with extrinsic factors

Objective:

to identify the prevalence of falls among older adults and the extrinsic factors associated with them.

Method:

population-based cross-sectional study with 350 older adults. A household survey was conducted using a questionnaire addressing socio-demographic, clinical, and environmental characteristics. Data were analyzed using Stata Software V.10. Pearson’s chi-square test and logistic regression analysis were used with stepwise criteria for selection of variables in the model, with measures of effect expressed in Prevalence Ratio. For input into the multiple model, the variables with p ≤ 0.20 were considered. All ethical care regarding research on human beings has been observed and respected.

Results:

the prevalence of falls was 46.9%. The extrinsic factors associated with falls were: stairs, uneven floor and pets in the main entrance, lack of anti-slip loose throw rugs and slippery floor in the kitchen, lack of anti-slip loose throw rugs and objects on the floor in the room, lack of grab bars in the shower, lack of grab bars in the toilet and switch away from the bathroom door (p <0.05).

Conclusion:

falls are frequent in long-lived adults. The identification of the extrinsic factors associated with the occurrence of this event can help in its prevention.

Sense of Coherence among Older Adult Residents of Long-Term Care Facilities in Taiwan: A Cross-Sectional Analysis

Background

Growing evidence shows that sense of coherence (SOC) is related to health promotion. Knowledge of SOC among older adults in Taiwan is limited. The present study aimed to investigate SOC status and its relationship to personal and environmental factors among older adult residents of long-term care facilities (LTCFs) in northeastern Taiwan.

Methods

This cross-sectional study was performed in Yilan, Taiwan. With face-to-face interviews, we obtained data from 104 LTCF residents (aged 65 years and older) using the Chinese version of Antonovsky's short 13-item SOC scale. We also collected the information on personal characteristics, physical and social environmental resources. Multiple linear regression was used to analyze factors potentially influencing SOC.

Results

Of the participants, the mean score (±standard deviation) of SOC was 58.3 (±8.8), while scores on SOC subscales (comprehensibility, manageability, and meaningfulness) were 23.4 ±4.5, 17.9 ±3.8, and 17.0 ±3.2, respectively. Education level, activities of daily living and number of LTCF staff were found to be independently associated with SOC status after adjusting for demographic characteristics, health status, and environmental resources. In addition, interactions between personal and environmental factors had a crucial influence on SOC status.

Conclusions

Participants in this study had relatively low SOC scores compared to their counterparts in Western countries. In addition to personal factors, environmental factors can play a significant role in SOC status among older adult LTCF residents. Comprehensive evaluation of SOC status should consider person-environment interaction effects.

Challenges for institutional elder care in Slovenian nursing homes

AIMS AND OBJECTIVES

To investigate deficiencies in the institutional elder care that is being offered to residents of nursing homes in Slovenia.

BACKGROUND

Public criticism of the provision of elder care in nursing homes is growing all over the world, including in Slovenia. Many studies on this issue have been conducted, but seldom have assessed different viewpoints simultaneously.

DESIGN

A qualitative research design that involved individual unstructured interviews was used in 2007. The participants (n=48) comprised 16 residents, 16 relatives and 16 members of the nursing staff from four nursing homes in Slovenia.

METHODS

The data generated were subjected to qualitative content analysis.

RESULTS

The major themes that emerged from this analysis were neglect, unprofessional communication, uncomfortable physical environment and inadequate administration.

CONCLUSIONS

The participants of the study identified issues in institutional elder care in Slovenia that have also been highlighted by international research. Due to staff shortages, low motivation, insufficient communication skills and inexperience, members of the nursing staff reported that they were not in a position to offer the best possible quality of care.

RELEVANCE TO CLINICAL PRACTICE

To improve the living environment in nursing homes, it is important to consider the opinions of all those who are involved closely in institutional elder care. Correction of deficiencies should be a priority and should result in more engagement with residents.

CONNECT for quality: protocol of a cluster randomized controlled trial to improve fall prevention in nursing homes

Background

Quality improvement (QI) programs focused on mastery of content by individual staff members are the current standard to improve resident outcomes in nursing homes. However, complexity science suggests that learning is a social process that occurs within the context of relationships and interactions among individuals. Thus, QI programs will not result in optimal changes in staff behavior unless the context for social learning is present. Accordingly, we developed CONNECT, an intervention to foster systematic use of management practices, which we propose will enhance effectiveness of a nursing home Falls QI program by strengthening the staff-to-staff interactions necessary for clinical problem-solving about complex problems such as falls. The study aims are to compare the impact of the CONNECT intervention, plus a falls reduction QI intervention (CONNECT + FALLS), to the falls reduction QI intervention alone (FALLS), on fall-related process measures, fall rates, and staff interaction measures.

Methods/design

Sixteen nursing homes will be randomized to one of two study arms, CONNECT + FALLS or FALLS alone. Subjects (staff and residents) are clustered within nursing homes because the intervention addresses social processes and thus must be delivered within the social context, rather than to individuals. Nursing homes randomized to CONNECT + FALLS will receive three months of CONNECT first, followed by three months of FALLS. Nursing homes randomized to FALLS alone receive three months of FALLs QI and are offered CONNECT after data collection is completed. Complexity science measures, which reflect staff perceptions of communication, safety climate, and care quality, will be collected from staff at baseline, three months after, and six months after baseline to evaluate immediate and sustained impacts. FALLS measures including quality indicators (process measures) and fall rates will be collected for the six months prior to baseline and the six months after the end of the intervention. Analysis will use a three-level mixed model.

Discussion

By focusing on improving local interactions, CONNECT is expected to maximize staff's ability to implement content learned in a falls QI program and integrate it into knowledge and action. Our previous pilot work shows that CONNECT is feasible, acceptable and appropriate.

Trial Registration

ClinicalTrials.gov: NCT00636675