Structure and Process-Related Fall Risks for Older Adults Living with Dementia in Nursing Homes
Background. There has been a steady increase in fall prevention research involving older adults living in Long-Term Care Facilities. Methodological issues inherent in some of these studies have limited comparisons among studies and their usefulness for evidence-based practice (EBP). Also, the influence of structure and process-related fall risk factors on fall rates in nursing homes (NHs) has not been reported.
Purpose. The purpose of the systematic review in this dissertation was to critically appraise methodological issues in extant fall prevention research. Using Donabedian's Model, the aim of the two pilot studies aim was to examine the feasibility of investigating the relationships between fall rates, structure and process-related fall risk factors in NHs; and, to determine the effect size of instruments and variance in this setting for future falls outcome research.
Design and Methods. This systematic review used the five stages of Whittemore and Knalf' (2005) review methodology to extract data from the databases, to summarize, and to synthesize the findings of the 10 studies included. The pilot studies used a survey design method to conduct study among: Study (1) 55 nursing staff from three NHs; and Study (2) 12 Directors of Nursing (DONs) and environmental observation in eight (n=8) of the NHs. Descriptive statistics, non-parametric tests, and regression analyses were used to estimate effects of organization and environmental fall risk factors on fall rates.
Results. There were inconsistencies in fall definitions, methods of data collection, and standards for reporting fall rates were apparent across the studies reviewed. Based on our findings, we conclude that larger studies are feasible among DONs and nursing staff, and environmental observation would be well supported by NHs. In the two pilot studies, a moderate- to-strong statistically significant relationship was found among fall rates, clinical policies, administration policies, staffing (in the nursing staff study), environmental factors and availability of assistive devices. However, in the study involving the DONs, the relationship between fall rates and staffing was a low negative and non-significant (r= -293, p=0.339). Findings in the pilot studies are limited by small sample sizes.
Implication. Standardized fall definition, methods of collecting data and reporting fall rates are necessary to make comparisons among studies as well as for EBP. DONs may be able to improve the rate of falls by targeting staff education, staffing, environmental issues, NH policies, and provision of assistive devices, further research is warranted.
Key Words: Nursing homes, Long-Term Care, Dementia, Environmental factors, Process-related factors, Structure-related factors, and Organizational factors