Identity construction in the very old: A qualitative narrative study

People are living longer internationally, with a growing number experiencing very old age (≥95 years). Physical, psychological and social changes can challenge one's sense of self and disrupt existing identities. However, experiences of the very old in society are seldom researched and how they construct identity and negotiate a sense of self is little understood. Our study focuses on participants aged >95 years to understand how identity is conceptualised to negotiate a continued place in society. Qualitative interviews with 23 people were thematically analysed, underpinned by Positioning Theory. Five themes were generated: A contented life; reframing independence; familial positioning; appearance and physical wellbeing; reframing ill health. Participants saw themselves as largely content and, despite their world becoming smaller, found pleasure in small routines. Perceptions of self were reframed to maintain autonomy within narrow parameters. Past relationships and experiences/events were drawn on to make sense of ongoing ways of living. There were tensions around feelings of loss of autonomy and independence, with some valuing these over issues such as safety. This sometimes conflicted with views of others and small acts of resistance and subversion were acted out to maintain some sense of control. However, participants minimised progressive ill health. Findings provide insight into how the very old may utilise identity to negotiate, acquiesce, resist and challenge the world around them.

Acceptability of a perturbation-based balance training programme for falls prevention in older adults: a qualitative study

INTRODUCTION

Perturbation-based balance training (PBT) is reported to effectively reduce falls in older adults and may even be superior compared with various exercise programmes. Due to the nature of the intervention, requiring unpredictable balance perturbations, the question arises whether acceptability is an issue in PBT.

OBJECTIVE

To evaluate the acceptability of PBT in older adults with a recent history of falls.

DESIGN, METHOD, PARTICIPANTS AND SETTING

This is a qualitative study in which semistructured interviews were conducted in 16 older adults (14 women and 2 men, mean age 73.6±6.0 years) who completed a three-session PBT protocol as part of another study in a university medical centre in the Netherlands. Typical case and purposive sampling strategies were applied. Interviews were based on the theoretical framework of acceptability (TFA) alongside context-specific factors and analysed using a template analysis approach.

RESULTS

The results indicate that this PBT protocol is perceived as acceptable by older adults with a recent history of falls and highlight key areas for potential future modifications. Enjoyment of the novel training and technology, being able to feel safe during training, and perceived impact of increased self-efficacy and balance confidence were identified as facilitating factors. Potential issues included initial apprehension or anxiety during training and perceived impact being predominantly psychological instead of physical. Complementary to the TFA one additional theme emerged which described challenges regarding the training setting, such as preference for group training in some participants and travel to the training location.

CONCLUSIONS

The results suggest that PBT is perceived acceptable by older adults with a history of falls. Increasing the social aspect of training and sharing the experiences of peers may be considered to enhance acceptability to new participants who initially feel apprehensive or anxious about their ability to participate in future implementation of PBT.

TRIAL REGISTRATION NUMBER

The article is linked to a randomised clinical trial registered on https://www.trialregister.nl/trial/7680, NL7680; Results.

Falls prevention for people with dementia: a knowledge translation intervention

Purpose

Strong evidence exists for falls prevention, yet uptake of strategies can be fragmented and limited. For people with dementia, adoption of strategies may be impacted by changes in memory and planning. This paper describes the findings of a knowledge translation intervention for adoption of falls prevention strategies for people with dementia.

Methods

Twenty-five dyads (people with dementia and their caregivers) participated in this mixed method intervention. The Knowledge to Action framework guided: collation of existing evidence into a useable format; identification of individual issues; understanding context; and evaluation of change over time. Demographic details, functional status, dementia severity, activity level, self-efficacy, falls risk and readiness to change behaviour were collected at baseline, 6 and 12 months. Goal setting and action planning using a discussion tool drove implementation.

Results

Falls rates were 5.4 falls per 1000 days for the 12-month period, with no significant change in functional capacity or self-efficacy. There was a non-significant trend towards reduced falls risk. Readiness to change behaviour for falls risk increased from 84% to 96% by 6 months, with most moving from contemplation into action ( n = 16), or preparation into action ( n = 36), with adoption of strategies high (82%).

Conclusion

Engagement with the person with dementia and their caregiver, through identification of their needs and preferences, and enabling choice resulted in high adoption of falls prevention strategies.

Health Practitioners' Perceptions of Falls and Fall Prevention in Older People: A Metasynthesis

Fall prevention has received a great deal of consideration and funding, however fall rates have not reduced accordingly. Health practitioners are key stakeholders in the process of implementing fall prevention evidence into their clinical assessment and management of older people at risk of falling. Investigating health practitioners' clinical experiences and perceptions has been identified as a means to enhance the translation of knowledge. Four databases were searched for studies exploring health practitioners' perceptions of falls and fall prevention. A metasynthesis of eight qualitative studies was conducted. The findings suggest that health practitioners face substantial barriers in the implementation of fall prevention practices. These include personal, interpersonal, and clinical barriers in addition to limitations of the research evidence. This knowledge hopes to enhance targeted dissemination of knowledge, reducing the research-practice gap and improving clinical outcomes for older people at risk of falls.

The beginning of the end: A qualitative study of falls among HIV+ individuals

Falls are an important concern for individuals living with HIV (HIV+). The purpose of this study was to understand perceptions of HIV+ individuals who had fallen regarding what caused their falls, prevention strategies that they used, and the impact of falls on their lives. Qualitative Description was the approach best suited to our study. We conducted in-depth interviews with 21 HIV+ individuals aged 47 to 71 years who had fallen within the past two years and who received care in a primary care/HIV clinic. Participants identified causes of falls as intrinsic (HIV, opportunistic infections, antiretroviral therapy, substance use, polypharmacy) or extrinsic (icy sidewalks, wet floors). Among those who felt that their falls could be prevented, prevention strategies included physical therapy and avoiding extrinsic fall risk factors. Some participants, however, felt that their falls could not be prevented. While some participants responded adaptively to falls, for many, the experience of falling was connected with deep feelings of loss and suffering. For these individuals, falls were understood to be "the beginning of the end" and a source of social isolation, changing family roles, diminished sense of self, and stigma.

Determinants of patient participation for safer care: A qualitative study of physicians' experiences and perceptions

OBJECTIVE

There is a paucity of research on physicians' perspectives on involving patients to achieve safer care. This study aims to explore determinants of patient participation for safer care, according to physicians in Swedish health care.

METHODS

We used a deductive descriptive design, applying qualitative content analysis based on the Capability-Opportunity-Motivation-Behaviour framework. Semi-structured interviews were conducted with 13 physicians in different types of health care units, to achieve a heterogeneous sample. The main outcome measure was barriers and facilitators to patient participation of potential relevance for patient safety.

RESULTS

Analysis of the data yielded 14 determinants (ie, subcategories) functioning as barriers and/or facilitators to patient participation of potential relevance for patient safety. These determinants were mapped to five categories: physicians' capability to involve patients in their care; patients' capability to become involved in their care, as perceived by the physicians; physicians' opportunity to achieve patient participation in their care; physicians' motivation to involve patients in their care; and patients' motivation to become involved in their care, as perceived by the physicians.

CONCLUSION

There are many barriers to patient participation to achieve safer care. There are also facilitators, but these tend to depend on initiatives of individual physicians and patients, because organizational-level support may be lacking. Many of the determinants are interdependent, with physicians' perceived time constraints influencing other barriers.

The Influence of Older Adults' Beliefs and Attitudes on Adopting Fall Prevention Behaviors

Among Americans aged 65 years and older, falls are the leading cause of injury death and disability, and finding effective methods to prevent older adult falls has become a public health priority. While research has identified effective interventions delivered in community and clinical settings, persuading older adults to adopt these interventions has been challenging. Older adults often do not acknowledge or recognize their fall risk. Many see falls as an inevitable consequence of aging. Health care providers can play an important role by identifying older adults who are likely to fall and providing clinical interventions to help reduce fall risks. Many older people respect the information and advice they receive from their providers. Health care practitioners can encourage patients to adopt effective fall prevention strategies by helping them understand and acknowledge their fall risk while emphasizing the positive benefits of fall prevention such as remaining independent. To help clinicians integrate fall prevention into their practice, the Centers for Disease Control and Prevention launched the STEADI (Stopping Elderly Accidents, Deaths, and Injuries) initiative. It provides health care providers in primary care settings with resources to help them screen older adult patients, assess their fall risk, and provide effective interventions.

Who Do We Think We Are? Disrupting Notions of Quality in Qualitative Research

The purpose of this article is to illuminate our troubles with, and troubling of, the trustworthiness dimension of balancing subjectivity and reflexivity, in qualitative research. This article evolved from debriefing sessions between three novice researchers working on a qualitative research study aimed at building understandings of the relational dynamics between adults with developmental disability diagnoses (ADevD) and their caregiving families. Following data collection, coauthors discussed interview experiences they had personally found challenging. These experiences constitute a point of departure for our examination of our researcher positions. We present a delineation of three research tensions, in the form of short "reflexive vignettes," each rooted in concern with possibly contradicting our goals of facilitating and expanding participant autonomy. We follow with recommendations about how, as researchers, our endeavor to understand participants with less conventional communication can be used to reflect and inform navigating difficulties universal to qualitative research.

An Exploratory Survey of Older Women's Post-Fall Decisions

This research examined factors influencing older women's post-fall decision making. We surveyed 130 independent older women from continuing care retirement communities and non-institutional homes. We categorized women's post-fall decisions as medical, corrective, and social decisions, and examined the associations between post-fall decision categories, decisional conflict, number of post-fall changes, self-rated health, frequency of falls, severity of falls, health literacy, awareness and openness to long-term care institutional options, and demographics. Older women experienced greater decisional conflict when making medical decisions versus social ( p = .012) and corrective ( p = .047) decisions. Significant predictors of post-fall decisional conflict were awareness of institutional care options ( p = .001) and health literacy ( p = .001). Future educational interventions should address knowledge deficits and provide resources to enhance collaborative efforts to lower women's post-fall decisional conflict and increase satisfaction in the decisions they make after a fall.

Discourse Analysis: Principles, Applications and Critique

With increasing attention being given to the use of qualitative methods in health research, there has been a concurrent growth in interest concerning different positions within the broad enterprise of ‘qualitative research’. Discourse analysis, a methodology falling within the postmodern tradition, has to date been little used within therapy research. This paper outlines the principles of discourse analysis, before reviewing the research literature in the fields of the therapies, nursing and medicine where discourse analysis has been used, in order to explore and clarify what this methodology can offer. Finally, a critique of discourse analysis is presented.

Determining the Effectiveness of a Falls Prevention Programme to Enhance Quality of Life: An Occupational Therapy Perspective

Falls are common in older people and become more frequent with advancing age. Falling in older people is associated with mortality, decreased mobility, premature nursing home admissions and a reduced ability to perform activities of daily living. In an attempt to reduce the incidence of falls, the National Service Framework for Older People has emphasised the need to develop falls services that provide support for older people who have fallen and use health promotion initiatives. While there is evidence to suggest that home modifications can reduce falls in older people, there has been little research to evaluate the effectiveness of occupational therapy falls prevention programmes.

This paper reports the findings of an evaluation of a multifaceted falls prevention programme, which aimed to determine whether occupational therapy could enhance quality of life by educating people aged 65 years and over about the risk of falls. A pre-intervention and post-intervention non-standardised self-administered questionnaire was completed at week 1 and at week 14. Of the 172 older people attending the falls prevention programme, 78 (45%) completed both questionnaires.

The findings from this study suggest that an occupational therapy falls prevention programme can reduce the impact of falls on older people by enhancing confidence to perform activities, which in turn can increase quality of life. However, further research is needed to determine the effectiveness of anxiety management techniques.

Older People and Mobility in the Home: in Search of Useful Assistive Technologies

A number of assistive technologies exist to help older people with their indoor mobility needs and there is an increasing recognition that older people are capable of being critical and active consumers of these technologies. This paper reports on a study that used focus groups and informal trials to explore older people's perspectives on their indoor mobility problems, their ideas on what assistive technologies might resolve these problems and their evaluation of assistive technologies that were developed in response to these ideas.

The analysis of the results from the four focus groups led to the development of a stair-climbing aid and a new cataloguing aid. The analysis of the results from the informal trials produced useful feedback on the design of the two products and indicated some limitations to the focus group methodology which could be addressed in future research.

Writing up Rigour: Representing and Evaluating Good Scholarship in Qualitative Research

Qualitative research is a mode of inquiry with which many occupational therapists engage and which some claim is particularly suited to researching the complexity and richness of occupational therapy practice.

This paper, written as part of a research series in this journal, has a dual purpose: first, to encourage qualitative researchers to identify their own ontology and use recognised strategies for ensuring high quality work which are consistent with their own world-view of research and, secondly, to consider how best to represent those strategies within their written accounts of their research.

Three researcher positions ranged along a continuum are proposed – realist, subtle realist and relativist – and alternative criteria for each of these positions are suggested. Occupational therapy and health examples are used to illuminate each of these traditions.

It is hoped that the paper will assist qualitative researchers both to clarify their own position along the research continuum and remain coherent within it and to identify the key features relating to quality and rigour that they should consider including in papers submitted for publication.

Older People's Views about Community Falls Prevention: An Australian Perspective

Although targets have been set for the establishment of falls prevention services, little is known about the views of older people in respect of such initiatives. The purpose of this study was to investigate the perspectives of the older participants in a community group falls prevention programme in Australia and to explore their views about the most and least useful aspects of the programme, using methods deriving from a grounded theory approach.

Semi-structured interviews were carried out with nine women and two men who had attended a falls prevention programme. The multifaceted intervention comprised seven weekly meetings of 2 hours each. The key principle underpinning the programme was enhancement of self-efficacy.

Four themes were identified through qualitative analysis: identity (focusing on participants as active elders); the salience of interventions (or the meaning attributed to different programme components); the social experience (the views about group interaction); and the consequences of participation. The participants were very positive about their experience of the programme and described a range of psychological and physical outcomes.

A decrease in the likelihood of a fall did not feature prominently in these interviews. It may be more meaningful to older people to embed falls prevention within a wider context of wellbeing and independence.

The causes of falls: views of older people with visual impairment

Background

Sight impairment increases with age and, compared with the general older population, older people with sight impairment are more likely to fall. There is a growing body of evidence on the views and perceptions of older people about falls, but little is published on the views of older people with sight impairment.

Objective

To explore what older people with sight impairment believe to be the causes of falls.

Design

A qualitative design was used, incorporating focus groups and interviews in which participants discussed falls and falls prevention. Framework analysis was employed to identify themes arising from participants' discussions of the causes of falls.

Setting and participants

Fifty‐four community dwelling men and women with sight impairment, aged 65 and over, were recruited from across Greater Manchester, UK.

Results

Five types of factors were identified that were believed to cause falls: (i) health issues and changes in balance caused by ageing; (ii) cognitive and behavioural factors; (iii) the impact of sight impairment on getting around the home; (iv) the impact of sight impairment on negotiating the environment away from home; and (v) unexplained falls.

Discussion and conclusions

Older people with sight impairment reported many researched risk factors previously identified by older people without sight impairment but also described many perceived risks unique to people with sight impairment. There are few interventions to prevent falls aimed at older people with sight impairment, and the results of this study allow further tailoring of such interventions based on views of older people with sight impairment.

What will they think? The relationship between self-presentational concerns and balance and mobility outcomes in older women

BACKGROUND/STUDY CONTEXT: Indirect evidence suggests that concerns over the impressions made on others (self-presentational concerns) may be associated with balance-related outcomes in older adults, but no empirical evidence exists to support this speculation. The present study examined the relationship between self-presentational concerns (social anxiety, social physique anxiety, and self-presentational efficacy) and functional mobility, accounting for age, balance confidence, falls, and muscle strength.

METHODS

Healthy women (60 years or older; N = 187) completed measures of self-presentational concerns, balance confidence, and fall history, and performed the timed up and go (TUG) test and a test of leg strength. Bivariate correlations were conducted. A hierarchical regression predicted TUG duration from the three self-presentational concerns, controlling for age, balance confidence, falls, and muscle strength to examine the unique variance in TUG duration explained by self-presentational concerns.

RESULTS

Self-presentational efficacy was a significant predictor of TUG duration over and above that of age, balance confidence, falls, and muscle strength. The results also showed significant correlations between social anxiety and self-presentational efficacy and TUG duration, between all three self-presentational concerns and balance confidence, and between social physique anxiety and self-presentational efficacy and falls.

CONCLUSIONS

Research is needed to examine the causal relationship between these outcomes. Investigating self-presentational concerns in older women may provide novel ways to impact balance-related outcomes in this population. Practical implications for clinicians are discussed, as the social and physical environment may influence self-presentational concerns in this population and subsequently impact assessment and treatment outcomes.

The meaning of the experience of anticipating falling

Falling in later life continues to be a critical issue in gerontology research, health professional practice and ageing health policy. However, much research in the area of fall risk and fall prevention neglects the meaning of the experiences of older people themselves. This humanistic interpretive phenomenological study explored the meaning of the experience of anticipating falling from the perspective of older people in order to foster a more person-focused approach to fall risk assessment and fall prevention. Individual semi-structured interviews were conducted with nine participants over the age of 65 living independently in the community. Follow-up interviews with two key informants were completed to inform the emerging interpretations. For older participants residing in the community, the experience of anticipating falling meant confronting their embodied lived-identity in the context of ageing. Experiential learning shaped how participants understood the meaning of falling, which constituted tacit, pathic knowledge of vulnerability and anxiety with respect to falling. Findings emphasise the importance of critically reflecting on the social experience of anticipating falling to develop effective and relevant fall prevention interventions, programmes and policies. A lifeworld-led approach to fall risk assessment and fall prevention resonates with these findings, and may encourage health-care providers to adopt a sustained focus on embodied lived-identity and quality of life when engaging older people in fall prevention activities.

Enacting Fall Prevention in Community Outreach Care

Despite increased international concern about fall prevention throughout the past 20 years, only limited attention has been paid to the experiences and perspectives of health care providers who deliver fall prevention programs. The purpose of this interpretive phenomenological study was to explore the meaning of the experience of enacting fall prevention, through individual semistructured interviews, among 6 members of an interprofessional geriatric outreach team in Ontario, Canada. Findings suggest that enacting careful practice was essential to the experience of enacting fall prevention, represented by four interrelated phenomenological themes: caring fully for older clients, carefully seeing older clients in their life contexts, enacting therapeutic relationships, and experiential learning in interprofessional teams. We discuss findings in relation to literature on emotional labor, leading to suggestions for the policy and practice of fall prevention.

Implementing person-environment approaches to prevent falls: a qualitative inquiry in applying the Westmead approach to occupational therapy home visits

BACKGROUND/AIMS

Despite evidence of the effectiveness of home safety interventions for preventing falls, there is limited uptake of such interventions within community services. Therefore, as part of a broader translational project, we explored issues underlying the implementation of an evidence-based home safety fall prevention intervention.

METHOD

We conducted in-depth interviews with eight occupational therapists and two programme coordinators engaged to deliver a home safety fall prevention intervention. Six community health centres within two metropolitan regions of Melbourne, Australia participated. The RE-AIM framework and Diffusion of Innovations theory underpinned the interviews which examine the enablers and barriers to implementing a home safety fall prevention intervention and integrating it into routine community preventive practice. Analysis involved thematic and content analysis.

RESULTS

Investment in the home safety for fall prevention intervention was supported and valued by coordinators and therapists alike, and a number of themes emerged which influenced implementation of this intervention. These included issues of: compatibility with organisational processes, individual practitioner practices and skills, a prevention approach, and client expectations; relative advantage in terms of flexibility of the process, client engagement and regional capacity building; complexity of implementing the intervention; and observability related to the invisible nature of fall prevention outcomes.

CONCLUSION

Implementation of this home safety fall prevention intervention was influenced by a range of interrelated organisational, practitioner and client related factors. The findings from this project provide insights into, and opportunities to increase the sustainable implementation of the home safety fall prevention intervention into practice.

What is the evidence of the experience of having a fall across the life course? A qualitative synthesis

BACKGROUND

Alleviating the economic and human impacts of falls and fear of falling are critical health and social care issues. Despite some proven effectiveness of a number of falls prevention intervention programmes, uptake remains low and attrition high. There is a need for greater understanding of social, cultural and individual, life course positioning of falling, actual or perceived.

OBJECTIVE

To address the question: what is the evidence of the experience of having a fall across the life course?

METHOD

A qualitative evidence synthesis with key electronic databases searched from 1990 to 2011 using terms related to the experience of falls and falling. Selected papers presented data from the perspective of the person who had fallen. Synthesis included collaborative coding of 'incidents' related to falling, theoretical sampling of studies to challenge emerging theories, and constant comparison of categories to generate explanations.

RESULTS

The initial focus was to access and assess the evidence for the experiences of a fall across the life course but the authors' systematic search revealed that the vast majority of the published literature focuses on the experience of a fall in later life. Only 2 of the 16 studies included, provided perspectives of falling from a life stage other than that of older adults. However older adults' perceptions of their falls experiences are likely to be influenced by lifelong attitudes and beliefs about falling and older age. Synthesis identified that a falls incident or fear of falling induces explicit or implicit 'Fear.' Consequences are related to notions of 'Control' and 'Social standing.' Recovery work involves 'Adaptation,' 'Implications,' 'Social standing' and 'Control.' 'Explanation' is sought.

CONCLUSIONS

How and why people make sense of falling across the life course should have positive impacts on developing falls intervention programmes that people will want to engage with and adhere to.

The Elizabeth Casson Memorial Lecture 2012: The Effectiveness, Impact and Legacy of Occupational Therapy

The Elizabeth Casson Memorial Lecture 2012, given on 13 June at the 36th Annual Conference and Exhibition of the College of Occupational Therapists, held at the Scottish Exhibition and Conference Centre, Glasgow.

Patients' willingness and ability to participate actively in the reduction of clinical errors: a systematic literature review

This systematic review identifies the factors that both support and deter patients from being willing and able to participate actively in reducing clinical errors. Specifically, we add to our understanding of the safety culture in healthcare by engaging with the call for more focus on the relational and subjective factors which enable patients' participation (Iedema, Jorm, & Lum, 2009; Ovretveit, 2009). A systematic search of six databases, ten journals and seven healthcare organisations' web sites resulted in the identification of 2714 studies of which 68 were included in the review. These studies investigated initiatives involving patients in safety or studies of patients' perspectives of being actively involved in the safety of their care. The factors explored varied considerably depending on the scope, setting and context of the study. Using thematic analysis we synthesized the data to build an explanation of why, when and how patients are likely to engage actively in helping to reduce clinical errors. The findings show that the main factors for engaging patients in their own safety can be summarised in four categories: illness; individual cognitive characteristics; the clinician-patient relationship; and organisational factors. We conclude that illness and patients' perceptions of their role and status as subordinate to that of clinicians are the most important barriers to their involvement in error reduction. In sum, patients' fear of being labelled "difficult" and a consequent desire for clinicians' approbation may cause them to assume a passive role as a means of actively protecting their personal safety.

The role of health professionals in promoting the uptake of fall prevention interventions: a qualitative study of older people's views

BACKGROUND

uptake of and adherence to fall prevention interventions is often poor and we know little about older people's perceptions of and beliefs about fall prevention interventions and how these affect uptake.

OBJECTIVE

to explore older people's perceptions of the facilitators and barriers to participation in fall prevention interventions in the UK.

METHODS

we undertook a qualitative study with older people who had taken part in or declined to participate in fall prevention interventions using semi-structured interviews (n = 65), and 17 focus groups (n = 122) with older people (including 32 Asian and 30 Chinese older people). This took place in community settings in four geographical areas of the South of England. The mean age of participants was 75 years (range 60-95). Data analysis used a constant comparative method.

RESULTS

older people reported that health professionals and their response to reported falls played a major role in referral to and uptake of interventions, both facilitating and hindering uptake. Health professionals frequently failed to refer people to fall prevention interventions following reports of falls and fall-related injuries.

CONCLUSIONS

consideration should be given to inclusion of opportunistic and routine questioning of older people about recent falls by practitioners in primary care settings. Referrals should be made to appropriate services and interventions for those who have experienced a fall to prevent further injuries or fracture.

Living with falls: house-bound older people's experiences of health and community care

Despite world-wide emphasis on falls prevention, falls and their consequences remain a major health issue for older people, and their health care providers. Many systematic reviews have been undertaken to evaluate the impact of intervention programmes on falls reduction, however, relatively little research provides a voice for older people's own perceptions of such programmes. To readdress this imbalance the current research utilized a purposive sampling method to recruit a hard to reach group of older people who had received a post-fall health and social-care programme to investigate their experiences of the programme. Semi-structured interviews with eight housebound people aged over 65 who had fallen were undertaken, and data analysed using interpretative phenomenological analysis. Four themes were identified: losing independence; losing confidence; losing social identity; managing a changed self. Despite a tailored intervention programme minimal improvement in participants' psychological adjustment to falls was noted. Outcomes from this study are of interest to health and social-care staff who deliver falls prevention programmes. Staff need to enhance constructive adjustment to the older person's altered circumstances and ensure behaviours do not exacerbate their clients' loss of independence. This should assist older people's ability to positively manage their sense of self, allowing them to find continuing meaning in their daily lives.

Predicting habitual physical activity using coping strategies in older fallers engaged in falls-prevention exercise

One third of adults over 65 yr old fall each year. Wide-ranging consequences include fracture, reduced activity, and death. Research synthesis suggests that falls-prevention programs can be effective in reducing falls by about 20%. Strength and balance training is the most efficacious component, and the assumed method of effect is an improvement in these performance domains. There is some evidence for this, but the authors have previously proposed an alternative method, activity restriction, leading to a reduction in subsequent falls through a reduction in exposure. The aim of this study was to examine physical activity in older fallers, applying a theory of adaptation, to ascertain predictors of habitual physical activity. Referrals to hospital- and community-based exercise programs were assessed for (a) habitual walking steps and (b) coping strategies, falls self-efficacy, social support, and balance mobility. There was no average group change in physical activity. There was high interindividual variability. Two coping strategies, loss-based selection and optimization, best explained the change in physical activity between baseline and follow-up. Notwithstanding some limitations, this work suggests further use of adaptation theory in falls research. A potential application is the creation of a profiling tool to enable clinicians to better match treatment to patient.

Representations of Old Age in Falls Prevention Websites: Implications for Likely Uptake of Advice by Older People

Introduction:

The representations of old age in falls prevention websites were explored and considered for their potential impact on older people's uptake of the advice.

Method:

Websites were searched for using the strategy of a previous systematic-style review and evaluated using the principles of discourse analysis.

Findings:

In the analysis of 33 websites, three main subject positions afforded to older readers were identified: (1) Passive recipients: victims of the ageing process, ignorant, ill-informed and vulnerable; (2) Rational learners: responsive to information, rational problem solvers and compliant with prescriptive advice; and (3) Empowered decision makers: actively engaged with and evaluative of information, autonomous and responsible for their course of action.

Discussion:

Falls prevention websites were rarely designed according to evidence-based recommendations concerning fit with positive self-identity and empowerment of active self-management of health. Although the representation of older people as passive and inert was most evident, the image of empowered decision makers was most likely to engage older people in preventing falls.

Conclusion:

Occupational therapists should ensure that they represent older people in a positive and respectful manner in falls prevention information, both that available through the internet and in written form.

Fear of falling from a daily life perspective; narratives from later life

Fear of falling is a well-known condition in later life. The aim of this study was to illuminate the experiences and the meaning of fear of falling in a daily-life context. The method used was a qualitative study inspired by interpretive phenomenology. In narrative interviews, five community-dwelling women over 80 years of age told about their fear of falling from a daily-life perspective. The overall thematic analysis resulted in three main themes: the meaning of managing daily life necessities; keeping in contact with the outside; living with fear. The findings showed that to live with fear of falling was to discipline daily life, and to learn to live with the challenge of a vulnerable bodily condition and of losing control at different levels: from falling, from incontinence, from dirt and from the stigma of being in a humiliating situation. The women created a perception of independence while they were dependent on help and community care and on news from the outside. At an existential level, they coped with their fear by strengthening their will. The conclusion was that the older women studied accepted the condition of fear of falling. They shared the ability to cope in various ways with the limitations of their bodily capacity and their imbalance.

Broadening our understanding: approaching falls as a stigmatizing topic for older adults

This theoretical paper aims to demonstrate that our current understanding of falls in older adulthood can be improved by viewing falls as a stigmatizing topic. Existing empirical research alludes to the stigmatization of falls for older adults, but until now the explicit link between the study of falls and stigma has not been made. After applying the concepts of identity threat, modified labeling theory, and attribution theory, the research implications of stigma on an older adult's willingness to report and discuss falls will be outlined. As many research investigations use the number of prior falls to assign individuals to study groups, the influence of stigma may be widespread and confounding research findings. By better recognizing and understanding the contribution of stigma to the willingness of older adults to report and discuss falls, we will be better able to mitigate its effects.

Psychosocial issues in Engaging Older People with Physical Activity Interventions for the Prevention of Falls

Dans cet article on présente une vue d’ensemble des facteurs psychosociaux ayant une influence sur la participation des personnes âgées aux interventions concernant l’activité physique et visant la prévention des chutes. On souligne l’importance des facteurs psychosociaux puisque les interventions seront rendues inutiles si elles ne réussissent pas à attirer la participation active des personnes âgées. La théorie du comportement planifié sert de cadre pour un examen de la façon dont les connaissances (un préalable), les attitudes, les normes subjectives (le contexte social) et la perception du contrôle comportemental (la confiance) encouragent ou entravent l’intention d’entre-prendre des activités pour la prévention des chutes. Cette étude est accompagnée de documents qui indiquent la manière dont la perception de soi influence l’intention. On termine par une discussion des recommendations recommendations du réseau européen Prevention of Falls Network Europe concernant l’implication des personnes âgées dans la prévention des chutes.

Determinants of participation in a fall assessment and prevention programme among elderly fallers in Hong Kong: prospective cohort study

AIMS

The study was undertaken to estimate the uptake rate of a fall prevention programme among older fallers and explore related factors.

BACKGROUND

Fall injuries are a major cause nationally of the loss of independence in old age, but they are preventable. Acceptance of fall prevention programmes is therefore important to reduce the risk of falling.

METHODS

Patients aged ≥60 attending the Department of Accident & Emergency of a regional hospital in Hong Kong between 2006 and 2007 were recruited. The study included a baseline interview, focus group interview and a cross-sectional 1-year follow-up telephone survey to assess uptake and its related factors.

RESULTS

A total 68% of 1194 older people attended the fall programme. Factors associated with programme participation included the perception of fall as being preventable [OR=3.47, 95% CI (1.59-7.56)] or recoverable [OR=1.73, 95% CI (1.06-2.82)], a safe outside environment; absence of chronic illness, and ability to walk without aids. Old-age people, those living in old-age homes and of lower education level were less likely to join the programme.

CONCLUSION

Older people with the selected characteristics were less likely to attend the fall prevention programme, thus were less likely to benefit from them. Support from family/carers may be an important element in participation. In a nursing context, in primary care practice, all of these factors should be taken into account in any future development of a fall prevention programme in Hong Kong of this nature.

Perceptions of health professionals about effective practice in falls prevention

PURPOSE

Falls prevention is a practice context with a rapidly expanding evidence-base. However, little is known about the implementation of this evidence into practice by health professionals. This study aimed to explore how falls prevention evidence is applied in practice internationally by health professionals working in the homes of older people, and to identify the perceived barriers and effective strategies in implementing falls prevention programs.

METHOD

A qualitative study design using a grounded theory approach was selected. Data were collected via focus groups or individual, semi-structured interviews with 50 health professionals from Australia, the UK and Canada. All participants visited older people in their homes as part of their usual practice. Data analysis used the constant comparative method.

RESULTS

Three themes emerged from the data: (i) client experiences of falls prevention, (ii) professional skills and clinical reasoning in falls prevention and (iii) service issues in falls prevention.

CONCLUSIONS

The complexity of delivering an evidence-based, multi-disciplinary falls prevention intervention that is acceptable to clients was described by participants. Challenges were identified in applying the evidence according to the resources and experience of health professionals in the systems within which they work.

Older Adult Fall Prevention: Perceptions, Beliefs, and Behaviors

Falls in adults aged 65 years and older are an important health issue associated with excess mortality, functional limitations, loss of independence, and reduced quality of life. Physicians can reduce the likelihood of falls in their older patients by incorporating prevention strategies into their clinical practice. Research has identified effective interventions, notably clinical assessment and risk factor reduction and exercise programs with balance training, that require older adults to adopt new behaviors. However, some older adults believe falls are an inevitable consequence of aging, while others do not see themselves as personally vulnerable. Factors that facilitate adopting fall interventions include social support, low-intensity exercise, and the perception that the programs are relevant. Barriers include fatalism, denial of risk, poor self-efficacy, and no previous history of exercise. To encourage their patients’ participation, physicians need to present fall interventions as lifestyle enhancing and as a way to remain independent. Messages should focus on positive health and social benefits such as improving balance and maintaining independence, rather than emphasizing negative information about falls and fall injuries. Along with the support of family and friends, a personal invitation from a health care provider will encourage older adults to take part in fall prevention programs.

Perceptions of older people living in the community about their fear of falling

PURPOSE

A fear of falls is widespread amongst older Australians. It increases the risk of falls and can lead to restriction of activity. The aim of this study was to gain insight into the precursors of a fear of falls and the experiences associated with this fear.

METHODS

Using a qualitative, phenomenological method, individual, semi-structured interviews were conducted with 9 community-based participants who reported moderate to high levels of fear of falling.

RESULTS

Most participants did not fear falling until they had experienced a fall themselves. The fear of falls was described as a negative experience, often linked with incapacitation, fear of dependence and having to leave their home. Participants chose to avoid falls by 'taking care'. Five themes emerged from data analysis: activity levels; view of the future; perceptions of fall experiences; fall avoidance; and development of fear of falls.

CONCLUSIONS

The results indicated that factors other than a fear of falling resulted in a restriction of activities for these participants; therefore, it cannot be assumed that a fear of falls alone results in reduction of activity. Fear of falls, in combination with other potential issues that could restrict activities, should be taken into account in the development of fall-prevention programs in order to ensure clients' needs are being met.

A systematic review of older people's perceptions of facilitators and barriers to participation in falls-prevention interventions

The prevention of falls is currently high on the health policy agenda in the United Kingdom, which has led to the establishment of many falls-prevention services. If these are to be effective, however, the acceptability of services to older people needs to be considered. This paper reports a systematic review of studies of older people's perceptions of these interventions. The papers for review were identified by searching electronic databases, checking reference lists, and contacting experts. Two authors independently screened the studies and extracted data on the factors relating to participation in, or adherence to, falls-prevention strategies. Twenty-four studies were identified, of which 12 were qualitative. Only one study specifically examined interventions that promote participation in falls-prevention programmes; the others explored older people's attitudes and views. The factors that facilitated participation included social support, low intensity exercise, greater education, involvement in decision-making, and a perception of the programmes as relevant and life-enhancing. Barriers to participation included fatalism, denial and under-estimation of the risk of falling, poor self-efficacy, no previous history of exercise, fear of falling, poor health and functional ability, low health expectations and the stigma associated with programmes that targeted older people.

How likely are older people to take up different falls prevention activities?

OBJECTIVE

To determine the extent to which older people are willing to engage in different falls prevention activities, and how this may vary in different sectors of the older population.

METHODS

A survey sent to patients aged over 54 in ten general practices in the Southampton, Bristol and Manchester areas of the UK in 2006 yielded 5,440 respondents. The survey assessed willingness to attend classes of strength and balance training (SBT), carry out SBT at home, or accept support to reduce home hazards. Participants were asked their gender, age, education, home tenure, ethnic group, and how often they had fallen during the past year.

RESULTS

Over 60% of the sample would consider doing SBT at home and 36.4% said they would definitely do SBT at home. Only 22.6% would definitely attend group sessions and 41.1% would definitely not attend. Older age, recent falls and lower socioeconomic status were associated with a greater willingness to carry out SBT at home (but not in classes) and accept help with home hazards.

CONCLUSIONS

Health promotion programmes should give prominence to home-based performance of SBT as a method of encouraging the entire older population to engage in falls prevention, including those most in need.

Patient falls: acute care nurses' experiences

AIM

To describe the findings from a qualitative study exploring acute care nurses' experiences with patient falls.

BACKGROUND

Patient falls continue to be a problem in acute care settings for nurses at the point of care. Despite the growing body of knowledge related to risk factors and interventions for fall prevention, minimal attention has been given to nurses' perspectives of patient falls.

DESIGN

A qualitative descriptive design was used.

METHOD

Focus group discussions were conducted with nurses working on a cross-section of inpatient acute care settings. Audio-taped sessions were transcribed and analysed thematically.

RESULTS

Nurses described their experience of falls as 'knowing the patient as safe', an ongoing affirmation that the patient was free from harm. In this focused, narrowly defined and highly specific knowing, nurses employed the key strategies of assessment, monitoring and communicating. Variable conditions influenced whether these strategies were effective in giving nurses the knowledge they needed to keep the patient safe. When strategies failed to provide nurses with knowledge of their patients as safe and patients fell, this created considerable stress for nurses and prompted them to use a range of coping strategies.

CONCLUSION

Knowing the patient as safe has the potential to resolve the tension between patient safety and independence. The critical, often taken for granted, activities used by nurses in this knowing must be expanded to include the meaning falls have for patients and attend to factors beyond nurses control such as environmental redesign and staffing.

RELEVANCE TO CLINICAL PRACTICE

Nurses play an important role in fall prevention through knowing the patient as safe but must be supported through the use of a multi-faceted approach extending from the individual nurse to the institutional level.

A Review to Explore how Allied Health Professionals can Improve Uptake of and Adherence to Falls Prevention Interventions

A literature review was conducted to facilitate allied health professionals' implementation of the recommendations made by the Prevention of Falls Network Europe (ProFaNE) (Yardley et al 2007a) on promoting older people's engagement in activities to prevent falls. The falls prevention literature was searched for relevant papers to aid allied health professionals' choice of strategies and to inspire ideas about how to implement ProFaNE's recommendations in everyday practice. Suggestions for each of the six ProFaNE recommendations are made, which may in turn promote older people's adherence to falls prevention interventions.

Older persons' perception of risk of falling: implications for fall-prevention campaigns

OBJECTIVES

We examined older people's attitudes about falls and implications for the design of fall-prevention awareness campaigns.

METHODS

We assessed data from (1) computer-assisted telephone surveys conducted in 2002 with Australians 60 years and older in Northern Rivers, New South Wales (site of a previous fall-prevention program; n=1601), and Wide Bay, Queensland (comparison community; n=1601), and (2) 8 focus groups (n=73).

RESULTS

Participants from the previous intervention site were less likely than were comparison participants to agree that falls are not preventable (odds ratio [OR]=0.76; 95% confidence interval [CI]=0.65, 0.90) and more likely to rate the prevention of falls a high priority (OR=1.31; 95% CI=1.09, 1.57). There was no difference between the groups for self-perceived risk of falls; more than 60% rated their risk as low. Those with a low perceived risk were more likely to be men, younger, partnered, and privately insured, and to report better health and no history of falls. Focus group data indicated that older people preferred messages that emphasized health and independence rather than falls.

CONCLUSIONS

Although older people accepted traditional fall-prevention messages, most viewed them as not personally relevant. Messages that promote health and independence may be more effective.

Evidence Review on Older People's Views and Experiences of Falls Prevention Strategies

BACKGROUND

A systematic review was undertaken of qualitative and quantitative studies and reviews that focus on older people's views and experiences of falls prevention. The review was undertaken to provide an additional dimension to the clinical effectiveness evidence provided by a Cochrane review on falls prevention (Gillespie et al. 2003) to inform the development of a national guideline on falls prevention in older people. As guideline recommendations or policies relating to preventive strategies have the potential to increase health care costs, it is important that all sources of evidence are reviewed by guideline development groups so that an understanding is achieved of the acceptability and sustainability of interventions in relation to different groups and settings.

METHOD

Accordingly, this review examined the literature on the views, preferences, and experiences of older people in relation to falls prevention strategies. Twenty-four studies meeting the inclusion criteria were critically reviewed and were then summarized into evidence tables. The key facilitators and barriers to participation in falls prevention programs were derived from the commonly occurring and consistent themes arising from the reviewed studies. The implications of these findings for the clinical effectiveness review conclusions were then taken into account.

FINDINGS

Several important findings emerged. These included preferences for falls prevention strategies not involving behaviour change among some groups, the need to promote the social value of falls prevention programs, and the importance of identifying and addressing factors associated with activity avoidance.

CONCLUSIONS AND IMPLICATIONS

In terms of the impact of these findings on the Cochrane review, the most important implication is that although trials of multifactorial falls prevention packages have reported beneficial results, in clinical practice it is important to consult with individual potential participants and find out what characteristics they are willing to modify, and what changes they are prepared to make to reduce their risk of falling. Otherwise, there is the risk that expensive programs are not properly targeted or fail to achieve maximum participation rates. Further work on the most robust and pragmatic methods of synthesizing disparate studies on patients' views and preferences to inform evidence-based guideline recommendations is needed.

What are older people prepared to do to avoid falling? A qualitative study in London

Falls prevention strategies form a significant part of recent government policy relating to older people. In this article we report a qualitative study to examine the extent to which older people are willing to adopt any of the following strategies in order to avoid falling; balance and lower limb strengthening exercises, home safety advice, and 'taking care'. A sample of community-dwelling inpatients who were more or less afraid of falling were interviewed. Some older people blamed their own unsafe behaviour rather than hazards in their home for falls, so taking care (moving slowly, holding on, being vigilant to and avoiding danger) was a widespread strategy. The benefits of exercise in falls prevention were poorly understood and there was little enthusiasm for exercising especially if it was perceived to be inappropriate in old age or painful. Awareness of home hazards and taking measures against them was common but home visits tended to be regarded as intrusive. Inadequate negotiation about adaptations was widespread and led to resentment and unwillingness to cooperate. Building on the widespread 'taking care' strategy may help educated older people in safe behaviour. Health professionals should encourage older people to exercise and when making home safety visits should confer with their clients, taking their preferences about adaptations into account.

A prospective study of the relationship between feared consequences of falling and avoidance of activity in community-living older people

PURPOSE

To identify the most common beliefs concerning the negative consequences of falling and determine whether these motivate avoidance of activity.

DESIGN AND METHODS

A questionnaire assessing feared consequences of falling was completed by 224 community-living people aged older than 75. Beliefs about the consequences of falling were related to demographic characteristics, falling history, and avoidance of activity. The questionnaires were completed again by 166 participants 6 months later.

RESULTS

Commonly feared consequences of falling were loss of functional independence and damage to identity. These fears were correlated with avoidance of activity (after adjusting for age, sex, and recent falling history) and predicted avoidance in activity 6 months later (after adjusting for baseline levels of avoidance).

IMPLICATIONS

Concerns about damage to social identity, as well as functional incapacity, are common and may motivate avoidance of activity.