Factors affecting adherence to use of hip protectors amongst residents of nursing homes—A correlation study

Compliance study of hip protector users for prevention of fragility fracture: A pilot randomized trial

BACKGROUND

Hip protectors have been widely used for hip fracture prevention in the elderly, but its efficacy remains controversial. Users' compliance to hip protector is an important factor for its efficacy. However, the assessment of users' compliance tended to be subjective and unreliable in the past.

OBJECTIVES

To quantify the elderly's compliance to hip protectors and investigate the effect of different underpant designs on the elderly's compliance.

STUDY DESIGN

A pilot randomized trial.

METHODS

Thirty-one participants were recruited and provided with hip protectors in which compliance monitors were installed and delivered with three pairs of either the conventional underpants or the purpose-design underpants randomly. Participants were encouraged to use the hip protectors with the assigned underpants for whole day. After 4 weeks, compliance data were downloaded from the compliance monitors. Participants were also asked to fill a survey form for acceptance analysis. The Spearman correlation coefficient and the Wilcoxon signed-rank test/2 independent samples t test/Mann-Whitney U test were used for the corresponding statistical analyses.

RESULTS

Thirty-one participants were recruited initially. Eighteen participants were excluded from instrumented compliance analysis because of limited or no data collection. The data of the resting 13 participants (six in the conventional underpants group and seven in purpose-design underpants group) were analyzed and showed an average instrumented compliance of 77.5% which was lower than the average self-reporting compliance (83.3%) of all the available 23 participants (eight of 31 became wheelchair-bounded). Participants' compliance was positively correlated with their acceptance to the hip protectors and significantly higher in the purpose-design underpants group than in the conventional underpants group ( P < 0.05).

CONCLUSIONS

This pilot study demonstrated a feasible protocol for compliance quantification of the elderly to the hip protectors, the importance to have an objective compliance measure to assess users' actual compliance, and purpose-design underpants could improve the users' compliance. Future studies with long-term observation and large sample size deserve further proof of the current findings.

The use of the PARIHS framework in implementation research and practice-a citation analysis of the literature

BACKGROUND

The Promoting Action on Research Implementation in Health Services (PARIHS) framework was developed two decades ago and conceptualizes successful implementation (SI) as a function (f) of the evidence (E) nature and type, context (C) quality, and the facilitation (F), [SI = f (E,C,F)]. Despite a growing number of citations of theoretical frameworks including PARIHS, details of how theoretical frameworks are used remains largely unknown. This review aimed to enhance the understanding of the breadth and depth of the use of the PARIHS framework.

METHODS

This citation analysis commenced from four core articles representing the key stages of the framework's development. The citation search was performed in Web of Science and Scopus. After exclusion, we undertook an initial assessment aimed to identify articles using PARIHS and not only referencing any of the core articles. To assess this, all articles were read in full. Further data extraction included capturing information about where (country/countries and setting/s) PARIHS had been used, as well as categorizing how the framework was applied. Also, strengths and weaknesses, as well as efforts to validate the framework, were explored in detail.

RESULTS

The citation search yielded 1613 articles. After applying exclusion criteria, 1475 articles were read in full, and the initial assessment yielded a total of 367 articles reported to have used the PARIHS framework. These articles were included for data extraction. The framework had been used in a variety of settings and in both high-, middle-, and low-income countries. With regard to types of use, 32% used PARIHS in planning and delivering an intervention, 50% in data analysis, 55% in the evaluation of study findings, and/or 37% in any other way. Further analysis showed that its actual application was frequently partial and generally not well elaborated.

CONCLUSIONS

In line with previous citation analysis of the use of theoretical frameworks in implementation science, we also found a rather superficial description of the use of PARIHS. Thus, we propose the development and adoption of reporting guidelines on how framework(s) are used in implementation studies, with the expectation that this will enhance the maturity of implementation science.

Nutritional Support and Physical Modalities for People with Osteoporosis: Current Opinion

Osteoporosis is a vital healthcare issue among elderly people. During the aging process, a gradual loss of bone mass results in osteopenia and osteoporosis. Heritable factors account for 60%-80% of optimal bone mineralization, whereas modifiable factors such as nutrition, weight-bearing exercise, body mass, and hormonal milieu affect the development of osteopenia and osteoporosis in adulthood. Osteoporosis substantially increases the risk of skeletal fractures and further morbidity and mortality. The effective prevention of fractures by reducing the loss of bone mass is the primary goal for physicians treating people with osteoporosis. Other than pharmacologic agents, lifestyle adjustment, nutritional support, fall prevention strategies, exercise, and physical modalities can be used to treat osteoporosis or prevent further osteoporotic fracture. Each of these factors, alone or in combination, can be of benefit to people with osteoporosis and should be implemented following a detailed discussion with patients. This review comprises a systematic survey of the current literature on osteoporosis and its nonpharmacologic and nonsurgical treatment. It provides clinicians and healthcare workers with evidence-based information on the assessment and management of osteoporosis. However, numerous issues regarding osteoporosis and its treatment remain unexplored and warrant future investigation.

Determinants of staff commitment to hip protectors in long-term care: A cross-sectional survey

BACKGROUND

If worn, certain models of hip protectors are highly effective at preventing hip fractures from falls in residents of long-term care, but modest acceptance and adherence have limited the effectiveness of hip protectors. Residents of long-term care are more likely to accept the initial offer of hip protectors and to adhere to recommendations concerning the use of hip protectors when staff are committed to supporting the application of hip protectors. Yet, we know very little about the nature of and factors associated with staff commitment to hip protectors in long-term care.

OBJECTIVE

To identify factors associated with staff commitment to hip protectors in long-term care.

DESIGN

A cross-sectional survey.

SETTING

Thirteen long-term care homes (total beds = 1816) from a single regional health district in British Columbia, Canada.

PARTICIPANTS

A convenience sample of 535 paid staff who worked most of their time (>50% of work hours) at a participating long-term care home, for at least one month, and for at least 8 h per week. We excluded six (1.1%) respondents who were unaware of hip protectors. Of the remaining 529 respondents, 90% were female and 55% were health care assistants.

METHODS

Respondents completed the Commitment to Hip Protectors Index to indicate their commitment to hip protectors. We used Bayesian Model Averaging logistic regression to model staff commitment as a function of personal variables, experiences with hip protectors, intraorganizational communication and influence, and organizational context.

RESULTS

Staff commitment was negatively related to organizational tenure >20 years (posterior probability = 97%; logistic regression coefficient = -0.28; 95% confidence interval = -0.48, -0.08), and awareness of a padded hip fracture (100%; -0.57; -0.69, -0.44). Staff commitment was positively related to the existence of a champion of hip protectors within the home (100%; 0.24; 0.17, 0.31), perceived quality of intraorganizational communication (100%; 0.04; 0.02, 0.05), extent of mutual respect between residents and staff and perceived contribution to quality of life of the residents they serve (100%; 0.10; 0.05, 0.15), and frequency of transformational leadership practices by respondents' primary supervisors (100%; 0.01; 0.01, 0.02).

CONCLUSIONS

We provide novel insight into the factors governing staff commitment to hip protectors in long-term care. Targeting of these factors could improve acceptance and adherence with hip protectors, thereby contributing to enhanced effectiveness of hip protectors to prevent hip fractures in long-term care.

Facilitators of and barriers to hip protector acceptance and adherence in long-term care facilities: a systematic review

BACKGROUND

Hip protectors represent an attractive strategy for reducing hip fractures among high-risk fallers in long-term care facilities. However, clinical studies yield conflicting results regarding their clinical value. This is mainly due to poor acceptance and adherence among users in wearing these devices. As a result, there is an urgent need to identify potential barriers and facilitators to initial acceptance and continued adherence with hip protector use.

PURPOSE

The objective of this systematic review is to synthesize available research evidence to identify factors that influence acceptance and adherence among older adults living in long-term care facilities.

METHODS

A key word search was conducted for studies published in English between 2000 and 2013 that employed quantitative, qualitative, or mixed-methods research designs. Two independent reviewers evaluated each article for inclusion, with a third reviewer when needed to resolve discrepancies.

RESULTS

Twenty-eight articles met our inclusion criteria, and facilitators and barriers were clustered into 4 socio-ecological levels: system (eg, facility commitment, staff shortages), caregiver (eg, belief in the efficacy of protectors, negative perceptions), resident (eg, clinical risk factors for falls and related fractures, acute illness), and product (eg, soft shell, discomfort).

DISCUSSION

The outcomes provide decision makers, health professionals, and caregivers with a greater awareness of strategies to improve compliance with the use of hip protectors. Furthermore, researchers can use this information to design clinical trials that yield high acceptance and adherence.

Hip Protectors: Are They Worth it?

Hip fractures are one of the most serious conditions in frail elderly subjects, greatly increasing morbidity and mortality, and decreasing healthy life years. Since their first introduction on the market, hip protectors have been revealed to be a potential preventive measure for hip fractures, in addition to other well-known recognized medical interventions and rehabilitation procedures. However, randomized controlled trials have given contradictory results regarding their efficacy. Moreover, little data are available on the cost effectiveness of hip protectors. Adherence is a major problem in assessing the effectiveness of hip protectors in preventing fractures. Indeed, there is a lack of general consensus on a standard definition and quantitative objective estimation of adherence to hip protectors, along with still scarce evidence on specific interventions on how to ameliorate it. From what is known so far, it seems reasonable to advise the use of hip protectors in aged care facilities, since recent pooled analyses have suggested their efficacy in this setting. The introduction of sensors combined with hip protectors will probably address this issue, both for monitoring and optimizing compliance, especially in elderly people. In the meantime, new, well-designed studies following specific guidelines are strongly encouraged and needed. In particular, studies in community-dwelling elderly individuals at high risk of first or further fragility fractures are required. The optimization of the tested devices in a preclinical setting according to international standard biomechanical testing is necessary.

Autonomy, choice, patient-centered care, and hip protectors: the experience of residents and staff in long-term care

The purpose of this study was to examine long-term care (LTC) resident and staff perceptions on the decision to use hip protectors and identify the factors that influence attitudes toward hip protector use. Staff (N = 39) and residents (N = 27) at two residential care facilities in British Columbia, Canada were invited to participate in focus groups on fall prevention and hip protector use. A total of 11 focus groups were conducted. Using framework analysis results show that residents and staff shared concerns on aesthetic and comfort issues with hip protectors. Residents also generally felt they did not need, or want to use, hip protectors. However, they also had desire to be cooperative within the LTC environment. Staff underscored their role in advocating for hip protector use and their desire to protect residents from harm. Practice considerations for facilities wishing to promote hip protectors within a patient centered framework are highlighted.

A mixed-methods approach to investigating the adoption of evidence-based pain practices in nursing homes

This mixed methods study examined perceived facilitators and obstacles to adopting evidence-based pain management protocols vis-a-vis documented practice changes that were measured using a chart audit tool. This analysis used data from a subgroup of four nursing homes that participated in a clinical trial. Focus group interviews with staff yielded qualitative data about perceived factors that affected their willingness and ability to use the protocols. Chart audits determined whether pain assessment and management practices changed over time in light of these reported facilitators and barriers. Reported facilitators included administrative support, staff consistency, and policy and procedure changes. Barriers were staff attitudes, regulatory issues, and provider mistrust of nurses' judgment. Overall, staff reported improvements in pain practices. These reports were corroborated by modest but significant increases in adherence to recommended practices. Change in clinical practice is complex and requires attention to both structural and process aspects of care.

Mechanisms which help explain implementation of evidence-based practice in residential aged care facilities: a grounded theory study

BACKGROUND

The context for the study was a nation-wide programme in Australia to implement evidence-based practice in residential aged care, in nine areas of practice, using a wide range of implementation strategies and involving 108 facilities. The study drew on the experiences of those involved in the programme to answer the question: what mechanisms influence the implementation of evidence-based practice in residential aged care and how do those mechanisms interact?

METHODS

The methodology used grounded theory from a critical realist perspective, informed by a conceptual framework that differentiates between the context, process and content of change. People were purposively sampled and invited to participate in semi-structured interviews, resulting in 44 interviews involving 51 people during 2009 and 2010. Participants had direct experience of implementation in 87 facilities, across nine areas of practice, in diverse locations. Sampling continued until data saturation was reached. The quality of the research was assessed using four criteria for judging trustworthiness: credibility, transferability, dependability and confirmability.

RESULTS

Data analysis resulted in the identification of four mechanisms that accounted for what took place and participants' experiences. The core category that provided the greatest understanding of the data was the mechanism On Common Ground, comprising several constructs that formed a 'common ground' for change to occur. The mechanism Learning by Connecting recognised the ability to connect new knowledge with existing practice and knowledge, and make connections between actions and outcomes. Reconciling Competing Priorities was an ongoing mechanism whereby new practices had to compete with an existing set of constantly shifting priorities. Strategies for reconciling priorities ranged from structured approaches such as care planning to more informal arrangements such as conversations during daily work. The mechanism Exercising Agency bridged the gap between agency and action. It was the human dimension of change, both individually and collectively, that made things happen.

CONCLUSIONS

The findings are consistent with the findings of others, but fit together in a novel way and add to current knowledge about how to improve practices in residential aged care. Each of the four mechanisms is necessary but none are sufficient for implementation to occur.

Literature review to identify factors that support implementation of evidence-based practice in residential aged care

The aim was to undertake a review of the literature on change management, quality improvement, evidence-based practice and diffusion of innovations to identify key factors that might influence the uptake and continued use of evidence in residential aged care. The key factors will be used to shape and inform the evaluation of the Encouraging Best Practice in Residential Aged Care Program which commenced in Australia in 2007. MEDLINE, CINAHL and the Cochrane Database of Systematic Reviews were searched using combinations of search terms. Searching focused on existing literature reviews, discussions of relevant conceptual and theoretical frameworks and primary studies that have examined the implementation of evidence-based practice in residential aged care. Keyword searching was supplemented with snowball searching (following up on the references cited in the papers identified by the search), searching by key authors in the field and hand searching of a small number of journals. In general, the period covered by the searches was from 2002 to 2008. The findings from the literature are often equivocal. Analysis and consolidation of factors derived from the literature that might influence the implementation of evidence-based practice resulted in the identification of eight factors: (i) a receptive context for change; (ii) having a model of change to guide implementation; (iii) adequate resources; (iv) staff with the necessary skills; (v) stakeholder engagement, participation and commitment; (vi) the nature of the change in practice; (vii) systems in place to support the use of evidence; and (viii) demonstrable benefits of the change. Most of the literature included in the review is from studies in healthcare and hence the generalisability to residential aged care is largely unknown. However, the focus of this research is on clinical care, within the context of residential aged care, hence the healthcare literature is relevant. The factors are relatively broad and cover the evidence itself, the process of implementation, the context within which evidence will be implemented and the systems and resources to support implementation. It is likely that the factors are not independent of each other. The set of factors will be refined over the course of the evaluation.

Osteoporosis: nonpharmacologic management

Osteoporosis is a chronic disorder of the skeleton causing increased bone fragility and fractures. In the second of our 3-part series, we discuss the beneficial effects of nonpharmacologic agents in the management of osteoporosis. We review the evidence supporting the use of exercise, whole-body vibration, hip protectors, low-intensity pulsed ultrasound, bracing, and vertebral augmentation procedures. The mechanism of action, precautions, and expected outcomes are discussed. Nonpharmacologic management of osteoporosis blends in very well with an overall exercise prescription. The nonpharmacologic interventions discussed are readily available and easy to implement. The use of such techniques demonstrates the important role of the physiatrist in the management of osteoporosis.

Nursing staff attitudes of hip protector use in long-term care, and differences in characteristics between adherent and non-adherent residents: a survey and observational study

BACKGROUND

Hip fractures represent an increasing public health burden with a simple fall to the floor as the most common cause. Because nursing home residents are particularly at risk, nursing homes should implement a broad range of fall prevention strategies. However, not all fall incidents can be avoided and external hip protectors may contribute to prevent hip fractures. A major problem in studying the effectiveness of hip protectors is residents' poor adherence. In nursing homes, adherence is dependent not only on the resident, but also on staff knowledge of and attitudes about hip protectors.

OBJECTIVES

To describe (1) attitudes of day versus night shift caregivers towards the use of a soft hip protector, (2) residents' adherence about the use of such protectors, and (3) differences in characteristics between adherent and non-adherent residents.

DESIGN

Survey and observational study.

SETTING

Nursing home.

PARTICIPANTS/METHODS

: Survey of care staff (n=37) in a nursing home after 8 months of continued application of a soft hip protector policy in residents (n=68). Adherence to wearing the hip protector, measured by weekly unannounced, randomly determined checks during day and night in the 8 months after the start of the study.

RESULTS

Overall, 85% agreed to wear a hip protector. At 8 months, only 29% was still wearing their hip protector; with significant differences between day and night shifts. Although virtually all caregivers (97%) considered a hip protector policy in residential care as feasible, the attitude towards hip protectors was found to be significantly different between day and night caregivers. Pain and discomfort, patient insight in the usefulness of these devices, interference with incontinence materials, and the overall resident mix and care acuity were reported as major barriers.

CONCLUSION

Implementing a hip protector policy for injury prevention in long-term care is not an issue of whether or not to use the devices. Rather, it is a continued clinical nursing decision process about when and when not, by whom and by whom not, why and why not, for how long, and to what clinical benefit--considering both the needs of the individual resident and the feasibility of such a policy in the context of resident mix and nursing staff.

Hip, Osteoporosis: New Paradigm

Osteoporosis is the most common metabolic bone disease. Recently, the paradigm for diagnosis and treatment of osteoporosis has undergone changes due to new findings on this disease. With the arrival of densitometers that could measure BMD we started using medications that block further degradation of density and repair the densitometric results. More recent findings, however, suggest that the BMD value influences the predicted success of future fracture prevention in less than 50%. The remainder is attributed to bone quality. There are a number of risk factors for osteoporotic fractures, some of greater and some of lesser significance. A small external force is necessary to cause an osteoporotic fracture; otherwise, the osteoporotic bone still does not break. The dominant factor in a fracture is therefore the fall of the elderly patient. Falls are preventable, although most are benign and injury free. Only in the recent decade have we started paying attention to the fall phenomenon, which does not only involve accidents, but is also a consequence of the normal aging process. Incidence of falls and hip fractures in residential elderly patients can be reduced with a multifactorial interdisciplinary prevention program (MIPP):• Staff training • Adaptation of environment • Gait and mobility exercise • Technical accessories • Revision of pharmacotherapy (psychotropics) • Hip protectors • Post-fall problem-solving conferences. Mobility exercise is useful in elderly groups; however, the maintenance of mobility is not linked to a reduction of fall risk. Hip protectors are protective pads designed to cover the greater trochanter and attenuate or disperse the force of fall sufficiently to prevent a hip fracture. A number of cost-benefit studies on residential elderly patients between 2004 and 2006 proved the efficacy of MIPP and hip protectors, and some studies did so also on those patients living independently. Unfortunately, as much as 75% of women and 90% ofmen at high risk in nursing homes are not investigated, and 75% of those affected are not treated.