This student-led demonstration project on

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1 A Student-Led Demonstration Project on Fall Prevention in a Long-Term Care Facility Alice Bonner, MS, APRN BC, GNP, FAANP, Patricia MacCulloch, MS, APRN BC, ANP, Terri Gardner, MS, APRN BC, GNP, and Chantel W. Chase, MA Falls are a frequent and serious problem facing people aged 65 and older. The incidence of falls increases with greater numbers of intrinsic and extrinsic risk factors and can be reduced by risk modification and targeted interventions. Falls account for 70% of accidental deaths in persons aged 75 and older. Mortality due to falls is significantly higher for older adults living in extended care facilities versus those living in the community. Our objective was to evaluate the effectiveness of a fall prevention training program in a long-term care setting. A single-group repeated-measure design was used, guided by the Precede Proceed framework. A comprehensive review of the literature and a concept analysis guided the development of testing and educational materials for all nursing and ancillary facility staff. Preliminary testing provided baseline data on knowledge related to fall prevention. Preand posttests, a fall prevention newsletter, and informational brochures were distributed to nursing staff and ancillary personnel at training sessions. Certified nursing assistant (CNA) champions were identified and given peer leadership training. Quick Tips fall prevention badges were also distributed to staff. Graduate students led interdisciplinary environmental rounds weekly, and new falls were reviewed on a daily basis by the interdisciplinary team. A 60-day posttest evaluated retention of fall prevention knowledge. Fall rates at baseline and for 2 months after the intervention were compared. Preliminary survey data revealed fall prevention learning opportunities, with a pretest mean score of 86.78%. Qualitative data were coded and revealed specific learning gaps in intrinsic, extrinsic, and organizational causes of falls. The 60-day posttest mean score was 90.69%; a paired t test (t score 1.050; P.057) suggested that learning may have taken place; however, differences in scores did not reach statistical significance. The fall rate before training was 16.1%; 30-day posttraining fall rate was 12.3%, and 60-day postintervention fall rate was 9%. Based on the program results, the model was expanded from long-term care to the university hospital system and outpatient clinics in the same community. The collaboration between a school of nursing and 1 long-term care facility led to the adoption of a significant quality improvement program that was subsequently extended to a local hospital and clinic system. Student-led projects designed to teach community service learning can be meaningful and can lead to changes in patient safety and quality of care. (Geriatr Nurs 2007;28: ) This student-led demonstration project on fall prevention in a long-term care facility was conducted in partnership with a 150- bed skilled nursing and rehabilitation facility in Worcester, Massachusetts. The faculty leader of the project, students, the executive director (ED), and director of nursing (DON) of the longterm care facility worked closely together in the planning and implementation of this program. Development of the Intervention Following the students comprehensive literature review on fall prevention in long-term care residents, 1 a quality improvement program was designed using the Precede Proceed framework. 2 This framework was chosen to guide the study because it is a populationbased, ecologically directed approach and could frame the health problems and characteristics such as morbidity, mortality, risk, and burden in the chosen sample. 2 The precede phases assess multiple factors that shape health status and assist the planner to arrive at a highly focused subset of those 312

2 factors as targets for intervention. The precede phases also allowed us to generate specific objectives and criteria for evaluation. The proceed portion of this framework provided additional steps for developing new policies and initiating the implementation and evaluation processes. The Precede Proceed model provided our program with a continuous series of phases in the planning, implementation, and evaluation of our work. In the next step of the implementation process, the clinical instructor and students set up a plan to meet weekly with the ED and DON of the long-term care facility to design the program. Using existing quality improvement data and recent state survey reports, the students listened to concerns from the DON and ED regarding falls in the facility. Brainstorming generated numerous ideas for the project, which were narrowed down to interventions that would have measurable outcomes and would address the facility s needs. These included an educational program by the students for all staff, identification of unit-based falls champions, weekly interdisciplinary rounds on the units, and falls data collection with feedback to the staff. Methods This study used a single-group repeatedmeasure design. All students and faculty participating in the study had completed Health Insurance Portability and Accountability Act (HIPAA) training, and those certificates were provided to the facility before the project began. No charts were reviewed, and no individual patients were seen by students as part of the protocol. The study was approved by the University of Massachusetts Institutional Review Board and the nursing facility s corporate executive committee. Staff members, including certified nursing assistants (CNAs), were recruited to participate in this study at unit meetings or in one-on-one interviews with the DON and ED. Participants were exposed to a single educational session on falls prevention provided by the nursing students. Testing was done and reviewed with the participants. Following the educational session for staff, champions were identified and trained to lead the fall prevention program, including providing instruction about falls prevention and appropriate interventions. A posttest was administered to all staff immediately following the educational session. To optimize learning of the material, the correct answers were reviewed with the entire staff after the posttests were handed in. All participants were ensured that their answers to the pre- and posttests would be kept confidential. Staff in the housekeeping and laundry departments was primarily Spanish-speaking, and those individuals were provided with tests translated into Spanish. Sample All staff members were considered eligible to participate in the program and were offered the learning opportunity. Of the 178 total nursing facility staff (nurses, CNAs, nonlicensed personnel), 8 licensed nurses 8 out of 40 or 16% of the licensed staff, 40 CNAs out of 90 or 44% of the CNA staff, and 20 out of 38 or 53% of nonlicensed personnel participated in the educational sessions. Altogether, we reached 40% of the total facility staff. Intervention The intervention process is outlined in Figure 1. All staff were invited to attend the 40-minute fall prevention in-service, and the staff scheduler assisted in assigning a time slot or session so that appropriate coverage of patient assignments could be arranged. Sessions were offered twice on each shift. Staff members who attended on their day off were compensated by the facility. Full participation by all staff was administration s major goal, and they worked with the students to arrange days and times for the presentations that would meet the needs of as many staff as possible. In sessions that included staff for whom the primary language was Spanish, the supervisor of the housekeeping department provided translation as needed. Drinks and light refreshments were provided during the presentations. Following the educational interventions, 4 CNA champions were identified and given peer leadership training. One CNA from each nursing unit was designated a falls champion and was trained to enhance surveillance efforts of fall prevention interventions as well as attend weekly fall prevention meetings coordinated by the DON. The 4 CNA falls champions were se- 313

3 Figure 1. Study Design. lected by the director based on overall job performance and leadership abilities. In addition to the fall prevention education materials, the students developed a Quick Tips badge to be worn by all staff. This badge was a checklist of caregiver responsibilities related to falls that each staff member could check before leaving a resident s room. The Quick Tips listed on the badge were: Eyeglasses and hearing aids on Hip protectors on Shoes on Bed in lowest position Call light placed within reach Assistive device in place No clutter Floors clean and dry Clinicians or researchers wishing to use or adapt the educational and training materials from this study may contact the author at abonner@mecf.org. Each week, students led interdisciplinary team rounds with facility staff, including the ED, DON, physical therapy, maintenance manager, housekeeping manager, charge nurses, and CNAs. During these walking rounds, the team would examine the physical safety of the environment, check functionality of assistive devices, and monitor employee techniques such as patient transfers, supervision of assistive devices, placement of laundry receptacles in hallways, and housekeeping and maintenance equipment use and storage. In addition, the students attended the weekly interdisciplinary falls meeting with facility staff. During these meetings held in the conference room, the team would discuss systems issues such as environmental safety, employee skills and training, and troubleshooting for equipment malfunction. Information from these meetings was later acted on by the facility staff members during their walk rounds in the facility. During weekly visits to the facility, students would speak with staff on each unit, receiving feedback from employees on how the staff felt about the progress of fall prevention efforts. This feedback was used to modify further fall prevention efforts. Students offered ongoing support to staff for participating in the program. Measures Falls were defined and documented by nursing staff using standard Minimum Data Set (MDS) 2.0 criteria. 3 This included residents who were found on the floor (unwitnessed fall), those who rolled out of bed, those who were lowered to the floor, and those who would have fallen if a staff member had not interceded. Fall rates were determined at baseline (January 2005 before the program); 30 days after the program (February 2005), and at 60 days (March 2005). Standard measure of falls per 100 residents was calculated. Knowledge of falls prevention was obtained using a 10-item test (Appendix A) developed specifically to evaluate the staff s knowledge 314

4 Figure 2. Fall rates percentage analysis. and ability to perform confidently and safely in the event of a fall. Pre- and posttest questions were developed by the students based on their review of the literature and in collaboration with facility administrative and nursing staff. Consideration was given to areas of weakness that had been identified during pretesting. Nine of the items were true false questions, and 1 item was an open-ended question to explore the staff s knowledge and beliefs about why residents fall. The nonlicensed staff (housekeepers, maintenance workers, dietary staff, and laundry personnel) were only asked to respond to 5 items that were most relevant to their work. The posttest, plus 3 additional questions (Appendix A) was used at 60 days following the original educational session to explore the retention of knowledge among the CNAs only. The 3 additional questions were added to assess for new knowledge that the students believed the CNAs had learned based on falls or situations that had occurred since the educational intervention. These 3 additional questions were not included in the statistical analysis. Given that this was a newly developed test, reliability and validity were not established. Data Analysis Descriptive statistics were done to describe test results. Paired t tests were used to compare differences on the 10-item pre- and posttest before and after the teaching intervention (the additional 3 questions added to the original posttest were not included). The open-ended question was analyzed using basic content analysis. 4 Content analysis was performed by the consultant/analyst and the students. Once coding was completed by all of the investigators, the codes were discussed until consensus of categories was achieved. Results A total of 40 CNAs completed the pre- and posttest on the day of the educational program, and 37 CNAs (93%) completed the 60-day posttest. The participants had a mean pretest score of 86.78% and a 60-day mean posttest score of 90.69% (t score 1.050; P 0.57). The facility fall rate prior to training was 16.1%. At 30 days posttraining, the fall rate was 12.3%. At the 60- day postintervention in March, the fall rate was 9% (see Figure 2). 315

5 Test results and the open-ended responses were considered and coded for specific themes. The findings revealed specific themes regarding intrinsic, extrinsic, and organizational factors for falls. Specifically, many staff members still did not correctly identify that residents should be supported on their strong side when assisting with transfers. Also staff members did not report that residents with an assistive device are at higher risk than those who did not require one for ambulation. Discussion There was no evidence of a statistically significant improvement in learning after the educational sessions; however, given the improvement in the fall rates, it seems that new information may have been used in practice. The results here suggest that the comprehensive fall prevention program may have been successful in increasing the knowledge of fall prevention strategies among nursing facility staff. The lack of statistical significance could have been related to a ceiling effect of the pretest (pretest mean score of 86.7%). The falls rate trended down over the 3-month period following the intervention, suggesting that the comprehensive approach of the educational program, use of falls champions and support of the gerontological nurse practitioner (GNP) students may have had some lasting benefit in falls reduction. Before the implementation of the study, we were concerned that the facility staff might not accept an educational program provided by nurse practitioner students. However, staff members seemed to embrace the idea of students participation and were open to attending educational seminars and listening to presentations. In addition, the strong support of the administrator and DON were critical to the success and sustainability of this project. As other studies have suggested, it is essential for leadership and management to get behind quality improvement efforts for effective change to take place. 5,6 In facilities without student involvement, the integration of multiple departments in fall prevention efforts can provide the impetus to increase awareness, educate staff, and make necessary changes in guidelines or policies. Based on issues that arose during the study, questions were added to the posttest that reflected issues related to leaving residents alone on the toilet, making sure eyeglasses and hearing aides were on, and identifying residents with a change in condition as having a higher risk for falls. This suggests that fall prevention efforts in a long-term care facility need to be customized to meet the educational needs of staff in a specific facility and that this may be an iterative process. Sustainability of the Falls Program The study findings were reported back to the staff and administration. In light of the positive findings, the administration revised the fall prevention policy to include aspects of this intervention. Specifically, administration felt that the inclusion of a discussion of falls during the daily morning meeting of nursing and administrative staff was critical to the falls prevention program, and this was incorporated into policy. It was believed that addressing falls at each morning report allowed for all managers to be up to date on resident safety, as well as to brainstorm new interventions to prevent future falls. This project also revealed the need for falls education prevention for all newly hired staff and an annual reeducation related to fall prevention, with job performance competencies for all personnel. It became the culture of the facility that the implementation of fall prevention strategies by the interdisciplinary team became everybody s responsibility. Program Impact on Students Following the implementation of this project, the GNP students extended their efforts on fall prevention into the adult ambulatory setting, implementing the Centers for Disease Control (CDC) and National Council on Aging Fall Prevention Toolkits into several clinical practice sites ( htm). The University of Massachusetts Memorial Family Medicine Clinic has adopted the CDC toolkit for their practice, distributing it to all of their patients aged 65 and older. In addition, providers are now asking about falls at each patient visit. The University of Massachusetts has embraced efforts to reduce both ambulatory and inpatient falls through their quality council for inpatient clinical coordinators, in efforts to begin a comprehensive fall prevention program throughout the hospital and clinic system. 316

6 The Massachusetts Extended Care Federation (MECF), the trade group for more than 450 proprietary and not-for-profit nursing homes, has used this same student program in several longterm care facilities across the state. MECF has made the fall prevention materials and quick tips badges available in an effort to assist longterm care facilities in the development of their own customized fall prevention program. Limitations This study had several limitations; the major limitation was the lack of a control group to compare to the intervention. Because of limited resources, we only collected data on CNAs, so it is not certain what impact the intervention might have had on nonnursing and licensed nursing staff. Learning was only assessed at baseline and 60 days; it is possible that the benefits of this 1-time program would not be sustained over longer periods of time. Future studies should consider reassessment at 1 year. The quality of the falls prevention plans and whether they were actually carried out at the resident level was not assessed; this could be done through audit processes that have been outlined in previous studies. 7,8 Repeated inservices or follow-up sessions or focus groups might have enhanced staff learning and improved clinical outcomes even more. Additional qualitative methods such as in-depth interviews would be helpful in identifying barriers to implementation of similar falls prevention programs. Conclusion and Future Recommendations The results from the collaboration of the University of Massachusetts Graduate School of Nursing and a local long-term care facility highlight the mutual benefit of a partnership between a school of nursing and a health care system. What began as a student-led demonstration project in 1 facility culminated in adoption of fall prevention programs not only at that long-term care facility but throughout a large local health care system including hospital, ambulatory, and other long-term care facilities. In addition, a statewide health care association (MECF) has been able to encourage replication of this program at additional long-term care facilities. Although the model in this feasibility study included graduate nursing students, similar models with community volunteers, family members, CNAs, and nonnursing department staff to champion falls prevention may also be successful. References 1. MacCulloch P, Bonner A, Gardner T. Comprehensive fall prevention programs across settings: a review of the literature. Geriatr Nurs 2007;55: 2. Green LW, Kreuter MW. Health promotion planning: an educational and ecological approach. 3rd ed. Mountain View, CA: Mayfield; Minimum Data Set 2.0. Baltimore, MD: Center for Medicare and Medicaid Services; Lincoln YS, Guba EG. Naturalistic inquiry. Thousand Oaks, CA: Sage; Taylor JA. The Vanderbilt fall prevention program for long-term care: eight years of field experience with nursing home staff. J Am Med Dir Assoc 2002;3: Anderson RA, Issel LM, McDaniel RR, Jr. Nursing homes as complex adaptive systems: relationship between management practice and resident outcomes. Nurs Res 2003;52: Schnelle JF, Ouslander JG, Simmons SF. Direct observations of nursing home care quality: does care change when observed? J Am Med Dir Assoc 2006;7: Wagner LM, Clark PC, Parmelee P, et al. Use of a content analysis procedure for the development of a falls management audit tool. J Nurs Measure 2005;113: ALICE BONNER, MS, APRN BC, GNP, FAANP, is an instructor at the University of Massachusetts Graduate School of Nursing Worcester, MA, and director of clinical quality at the Massachusetts Extended Care Federation in Newton Lower Falls, MA. PATRICIA A. MACCULLOCH, MS, APRN BC, ANP, is an adult nurse practitioner in the Department of Orthopedics at the University of Massachusetts Memorial Department of Orthopedics in Worcester, MA. TERRI GARDNER, MS, APRN BC, GNP, is a graduate student at the University of Massachusetts, Worcester, MA. CHANTEL WILSON, MA, is an independent consultant. ACKNOWLEDGMENTS The authors acknowledge the entire staff at Autumn Village Skilled Nursing and Rehabilitation Center, Worcester, Massachusetts, for their dedication to their residents and to nursing home fall prevention. APPENDIX A Pre- and Posttest Questions Name: Date:. CERTIFIED NURSING ASSISTANT POSTTEST 1. True/False Nursing Assistants have an important role in fall prevention and awareness. 2. True/False When a resident utilizes a cane or walker they re at less risk of falling. 3. True/False When transferring a resident with a weak side, I should assist from the weak side. 317

7 4. True/False Hearing and vision loss are not associated with falls. 5. True/False Knee and hip pain are not related to falls. 6. True/False A bed or chair alarm will keep my resident safe. 7. True/False Dizziness is a normal part of aging. 8. True/False Keeping resident rooms free from clutter is the housekeeper s responsibility. 9. True/False I am only responsible for those residents that are on my assignment. 10. Why do residents fall? The following 3 questions were added to the posttest but were not included in the statistical analysis: 11. True/False It is alright to leave my resident on the toilet and go help another resident. 12. True/False When my patient seems different from usual, they could be more likely to have a fall. 13. True/False Eyeglasses and hearing aides should be on my resident before transferring them /07/$ - see front matter 2007 Mosby, Inc. All rights reserved. doi: /j.gerinurse