HEALTH EDUCATION RESEARCH
Vol.30 no.2 2015 Pages 298–308 Advance Access published 8 December 2014
The effectiveness of a participatory program on fall prevention in oncology patients Li-Chi Huang1,2, Wei-Fen Ma1,2, Tsai-Chung Li3, Yia-Wun Liang4, Li-Yun Tsai2 and Fy-Uan Chang2* School of Nursing, China Medical University, Taiwan, 2Department of Nursing, China Medical University Hospital, No. 2 Yuh-Der Road, Taichung 40447, Taiwan, 3Graduate Institute of Biostatistics, China Medical University, Taichung, Taiwan and 4Department of Senior Citizen Service Management, National Taichung University of Science and Technology, Taichung, Taiwan *Correspondence to: F.-U. Chang. E-mail: [email protected]; [email protected] Received on September 4, 2013; accepted on November 12, 2014
Abstract
Introduction
Falls are known to be one of the most common in patient adverse events. A high incidence of falls was reported on patients with cancer. The purpose of this study was to explore the effect of a participatory program on patient’s knowledge and self-efficacy of fall prevention and fall incidence in an oncology ward. In this quasi-experimental study, 68 participants were recruited at a medical centre in Taiwan. A 20min fall prevention program was given to patients. A questionnaire was used to evaluate the effectiveness of program after on day 3 of intervention. The data of fall incidence rates were collected from hospital record. Fall incidences with and without the program were used to compare the effectiveness of intervention. The patients’ knowledge and self-efficacy of fall prevention are better than after intervention. A statistically significant difference in fall incidence rate was observed with (0.0%) and without (19.3%) the program. Our findings suggest that the fact of the bedside is that the most risk for falling in hospital must be communicated to the hospitalized patients. Educating patients about fall prevention and activities associated with falling increases their awareness of the potential of falling and promoting patient safety.
Patient safety is an important issue in hospitals, and the incidence of patient falls is a distinct indicator of quality health care throughout Taiwan. The Taiwan Joint Commission on Hospital Accreditation (TJCHA) declared that risk factors for inpatient falls must be reduced [1]. According to the TJCHA records, 7805 falls occurred in hospitals in 2009, of which 52% resulted in injuries [1]. One study in the United States that included 315 718 falls between 2006 and 2008 reported that 26.1% of falls resulted in injuries [2]. Falls during hospitalization have resulted in fracture, head trauma and other serious injury [3]. Falls and their sequelae increase medical costs, adding to the financial burden already incurred by the patient’s hospital stay [4, 5]. Falling can lead to increased medication, activity restriction, further decline in physical function, greater risk of future falls and lower quality of life [5]. This highlights the importance of teaching patients how to prevent falls during their hospitalization. Falling is defined as an unexpected drop to the floor or other flat surface (Taiwan Quality Indicator, Taiwan). Falls must be recorded in medical charts and reported by all certified health institutions (Taiwan Quality Indicator, Taiwan). A high risk of falling is associated with gait instability, agitation or confusion, urinary incontinence/frequency, prior
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doi:10.1093/her/cyu072
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1
Falling prevention participatory program in oncology patient sufficient effort to achieve a certain performance level. Moreover, self-efficacy is an important variable that affects patients’ self-care and satisfaction and is observable as a determinant of competence [15–17]. Fall self-efficacy scales were developed to measure confidence in performing activities of daily living without falling in community settings [17–18]. However, no fall efficacy scale is available in the hospital setting. Many fall prevention strategies are derived from the evidence obtained from clinically stable people living in their own homes [19–21]. Several studies have reported modest effects on fall prevention through structured, multifaceted interventions among hospital inpatients [22, 23], geriatric patients [20, 21] and cancer patients [6, 8, 9]. These studies indicate that oncology patients are at a high risk of falling, and interventions must be provided to increase knowledge and prevent falls in this population. However, there is a lack of evidence showing how health education affects falls among cancer patients in oncology departments. An effective fall program is needed that not only provides accurate information but also enhances the patient’s confidence in managing his or her own risk. Thus, we developed a Fall Prevention Participatory Program (FPPP) to address gaps in the knowledge and competency of oncology patients when managing their own fall risk in a hospital setting. This program was empirically evaluated for its effectiveness in changing the knowledge and self-efficacy and fall incidence rate.
Methods Design A quasi-experimental design was used to investigate the effectiveness of FPPP in oncology patients. The study was conducted in two parts. In part I, we implemented a single-group pretest and post-test design using a self-report questionnaire to evaluate the change of patients’ knowledge and self-efficacy of fall prevention. Patients’ knowledge and self-efficacy of fall prevention in hospital were tested on admission (pretest) and on day 3 (post-test); FPPP 299
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history of falls, administration of ‘culprit’ drugs (sedatives/hypnotics), sensory neurological deficits and impaired physical functions such as blurred vision, weak gait, poor cardiovascular function and low hemoglobin [6–9]. In addition, environmental factors may also contribute to the risk of falling [7]. Studies have shown that diagnosis of advanced cancer confers a greater risk of falling than that with other illnesses [6, 8, 9]. Reports show that one in two patients with advanced cancer fall during a 6-month period, due to the nature of treatment and generally longer hospital stays than those in patients with other diseases [8]. Thus, effective intervention to reduce falls is particularly needed in oncological clinical practice. Prevention of inpatient falls is a principal tenet of health policies in medical institutions. Effective fall prevention begins by assessing risk factors and screening high-risk patients [8, 10, 11]. Identifying potential risk factors is the first step in the primary and secondary preventions of injury [8]. Risk factor assessment may heighten the need for vigilance among medical staff, patients and caregivers. Various fall assessment tools, including the STRATIFY and Morse risk-rating scales, are commonly used for measurement and prediction of falls with high sensitivity and specificity [10–12]. Although several fall risk assessment tools are available, no single tool is completely appropriate for every cancer care setting [8]. Once risk factors have been assessed, caregivers and nurses should pay more attention to patients at high risk. An alternative fall prevention strategy is to improve the patient’s self-efficacy. Many patients lose their sense of control over the disease and their lives [13]. Thus, self-efficacy is an important component of success in self-care [13, 14]. Researchers have found that self-efficacy can predict the likelihood of a patient implementing health-related behaviors, when actual behaviors cannot be measured [13–15]. The concept of self-efficacy was developed by Bandura and is defined as an individuals’ confidence in his or her own ability and competence to complete tasks in certain situations [16]. Task completion or abandonment depends on the degree of selfefficacy; people with high self-efficacy expend
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Participants Subjects were recruited through convenience sampling of patients admitted to an oncology ward at a level three medical center in the central district of Taiwan. Patients aged 18 years who were admitted for cancer therapy were invited. Patients were excluded from this study if they were unconscious, had suicidal ideation or intent or had a psychiatric diagnosis. Optimal sample size was achieved using mathematical equations for comparing two density incidence rates in part II of the study [24]. The mean monthly fall incidence was 13% (per 100 patientdays) in the oncology ward in 2010. To detect a fall incidence of 4% (per 100 patient-days; hospitalwide average in 2010) with a difference of ¼ 0.05, 52 subjects were needed to achieve a power of 80% to detect statistically significant differences. The effect was selected when the smallest effect would be important to detect the difference in fall prevention knowledge and self-efficacy before and after the intervention with a difference of ¼ 0.05 (part I of the study). With a sample size of 60, the study had a power of 99% to yield a statistically significant result. We first enrolled 79 hospitalized patients for part I of the study. After undergoing chemotherapy, 19 patients withdrew because of deteriorating medical conditions and an inability to complete the post-test questionnaire. In total, 60 participants completed the pretest and post-test questionnaires, providing a 76% completion rate in the intervention group. In part II, to evaluate the effectiveness of intervention, data of intent-to-treat was included. Thus, a 300
total of 68 participants were in the intervention group by including eight participants who were hospitalized 3 points were considered at a high risk of falling [26]. The second subscale consisted of 20 true/false items regarding the fall prevention knowledge,
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was delivered after the pretest. In part II, to evaluate the effectiveness of intervention, a two-independent group design was used. We analyzed the fall incidence rate of the sample during the FPPP intervention and a matched sample from the period prior to the intervention to compare the effectiveness of the intervention. Fall incidence data were collected from hospital records of observed falls. These data were collected in the same oncology unit from March to May 2010 (no intervention) and 2011 (intervention).
Falling prevention participatory program in oncology patient
including hazardous situations (seven items), awareness of information (nine items) and environmental conditions (four items). The third subscale included 15 items concerning patients’ self-efficacy of fall prevention. These questions were designed to assess the patient’s confidence regarding fall prevention during hospitalization, personal activities of daily living (nine items), and instrumental activities of daily living (six items). Each subscale was developed to be suitable for the hospital environment. Items were scored on a four-point Likert scale from ‘very concerned’ (4) to ‘not at all concerned’ (1). Higher scores indicated better fall prevention knowledge and a higher level of selfefficacy of fall prevention. The instrument’s readability, accuracy and adaptability were adequate, as determined by an expert panel of reviewers and a pilot study among 15 patients. The panel consisted of experts in hospital management, health education, oncology care nursing, nursing administration supervision and statistics (one each). The face validity of the instrument was determined by an expert reviewer
with a Core Values IndexTM estimate of 0.9 [27]. The reliability of the instrument was determined in the pilot study. The internal consistency of the instrument was measured using the Kuder– Richardson Formula 20, resulting in a score of 0.66 in patients’ knowledge of fall prevention. Cronbach’s alpha was 0.95 for patients’ self-efficacy of fall prevention.
Data collection and analysis This study was approved by the Institutional Review Board of the university hospital (DMR-100-038). In part I, each patient was assessed for fall risk at initial encounter. Patients admitted to the oncology ward who met the inclusion criteria were invited to participate in the study and informed consent was obtained. The FPPP intervention was implemented after completing the pretest questionnaire. The post-test questionnaire was conducted on day 3 of hospitalization. In part II, the fall incidence was defined by the incidence density, which was defined as the number of falls divided by the total number of inpatient days 301
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Fig. 1. The process of enrollment and intervention allocation in two groups.
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Results
Table I. Demographic data of two groups for fall incidence evaluation Intervention (n ¼ 68) Variable
n (%)
Age 3). Cancer patients were aged 47.8 years on average, which was much younger than the average of hospitalized cancer patients in other studies [6–8] and is consistent with the notion that aging may not be a risk factor for falling in patients with cancer. It appears that the prevalence of falls is related to factors other than demographics [8]. In this study, a high proportion of medication usage (91.7%) and poor sleep status (83.3%) were revealed as risk factors for falling. However, these results may be subject to selection bias because patients hospitalized for cancer treatment may be more likely to use medication and have disturbed sleep patterns compared with those in patients with other diseases.
Patients’ knowledge of fall prevention In this study, the impact of FPPP was evaluated among hospitalized cancer patients and participation increased the fall prevention knowledge in the cohort of patients. Our results are consistent with those of other studies of fall prevention, in which knowledge was increased through a health program for the elderly [22, 23]. 303
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Variable
L.-C. Huang et al. Table III. The comparison of participant’s knowledge of fall prevention before and after intervention (N ¼ 60)
Variable
*P < 0.05, **P < 0.01, ***P < 0.001 McNemar test. % indicates the correctness rate. b F indicates false answer of question c T indicates true answer of the question. a
304
After intervention correctness n(%)a
P-value
Tb T
55 (91.7) 58 (96.7)
60 (100) 58 (96.7)
0.063 1.0
F
45 (75.0)
54 (90.0)
0.035
T
59 (98.3)
60 (100)
1.0
T
60 (100)
60 (100)
1.0
F
27 (45.0)
42 (70.0)
0.001**
T
58 (96.7)
59 (98.3)
1.0
T
57 (95.0)
59 (98.3)
0.50
T F T Fc
54 5 59 28
60 44 60 41
0.310 0.000** 1.0 0.002**
F
33 (55.0)
54 (90.0)
0.000***
T
56 (93.3)
60 (100)
0.125
T
55 (91.7)
60 (100)
0.063
T
59 (98.3)
60 (100)
1.0
F
14 (23.3)
34 (56.7)
0.000***
F
28 (46.7)
49 (81.7)
0.000***
F
19 (31.7)
46 (76.7)
0.000***
F
18 (30.0)
46 (76.7)
0.000***
70.7 14.12 ± 2.156
88.8 17.77 ± 1.854
0.000***
(100) (8.3) (98.3) (46.7)
(100) (73.0) (100) (68.3)
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Fall may cause bleeding, endangering life Patients in hospitalized over age 65 likely to falls than other group because of poor eye vision and joint activity According to the statistics of falls, the more prone to falls are women By taking blood pressure medicine, tranquilizers, sleeping pills diuretics, hypoglycemic, analgesics, anti-histamine medicine, patients are prone to fall because medicines may cause dizziness, vertigo, hypotension Medication or disease could cause postural hypotension. It should adopt a progressive out of bed, sit in the bedside 5–10 min, wait until no dizziness or discomfort, then get out of bed When I want to get up for toilet at midnight. I can get up out of bed and slowly walk to the toilet even if no company or my family were asleep My body may become weak in hospitalized. It should be slowly movement while get up or out of bed It is better to have a sedative hypnotics after the toilet In order to avoid the fall risk after taking medicine Using sedative hypnotics is easy to have dizziness The location most prone to fall in the hospital is the bathroom Aisle or bedside cannot put sundries for preventing falls because The wet floor in the room or toilet, I can wait until cleaners to wipe it dry For the convenience of getting out of bed, it doesn’t need the bed rail. Only need the bed rail while sleeping in the night time Standing up after the toilet is easy to have postural hypotension and led to fall Don’t leave the ward during the injection of painkillers for preventing fall When you want to get out of bed but feel dizzy and no family around. It’s better to use the calling bell, asking nurses for help The caregiver can leave while patient is sleep; and get back as soon as possible The moveable IV stand can be placed at the end of the bed for preventing fall The commode chairs should be placed in the bathroom for maintaining a tidy environment The slippers should be placed outside the bathroom when taking a shower because slipper would get wet that cause fall Average correctness percentage Mean ± SD
Correct Answer
Before intervention correctness n (%)a
Falling prevention participatory program in oncology patient Table IV. The comparison of participants’ self-efficacy before and after intervention (N ¼ 60) Before intervention Mean ± SD
Variables
P value
3.13 ± 0.98 2.65 ± 1.04 2.90 ± 0.90 2.93 ± 0.90 3.32 ± 0.95 2.87 ± 1.08 2.70 ± 0.94 3.23 ± 0.85 2.68 ± 1.11
3.13 ± 0.93 2.83 ± 0.98 3.13 ± 0.85 3.25 ± 0.90 3.43 ± 0.79 2.90 ± 0.97 3.05 ± 0.93 3.33 ± 0.88 2.88 ± 0.96
1.000 0.101 0.008** 0.007** 0.211 0.788 0.007** 0.307 0.135
3.05 ± 1.10
3.22 ± 0.96
0.214
3.13 ± 0.93 3.48 ± 0.73 3.25 ± 0.91
3.30 ± 0.85 3.62 ± 0.61 3.42 ± 0.79
0.115 0.117 0.115
3.37 ± 0.80
3.32 ± 0.81
0.635
3.35 ± 0.82 46.05 ± (11.58)
3.40 ± 0.83 48.27 ± (10.72)
0.635 0.043*
*P < 0.05, **P < 0.01, paired t test.
Table V. The comparison of fall incidence between the patients with/without the intervention Intervention (2011)
No Intervention (2010)
Number of total inpatient day
Frequency of falls
Incidence of falls (per 100 day)
Number of total inpatient day
Frequency of falls
Incidence of falls (per 100 day)
Z value
1009
0
0.00
1557
3
19.3
1.98*
The pretest answers were most frequently incorrect for question #10, ‘The location (at which a patient is) most prone to falls in the hospital is the bathroom’ (8.3%). However, scores for this question noticeably increased after the intervention (73%). According to the TJCHA’s patient safety report [1], most fall events during hospitalization occur at the bedside (27.6%), whereas with the second most common location being the bathroom (19.5%). After hospital admission, changes in body function and effects of medical treatment may affect body balance while getting up from a bed or chair [28]. Thus, the fact that most falls occur at the bedside, rather than in the bathroom, should be considered
for hospitalized patients, particularly those with cancer. Differences between home and hospital environments as well as in the patient’s physical condition may increase the fall risk among hospitalized patients. Research has shown that this can be reduced by implementing multifactorial fall prevention strategies that include fall risk assessments, door/bed fall risk alerts, environmental modifications and additional assistance with toileting [23, 29–32]. Through education, risk factor assessment, discussion and implementation of FPPP, patients were able to strengthen their knowledge of fall risk and participate in their own risk management. Patients being more 305
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Being in toilet Getting dressed/undressed Getting in/out of bed Getting up to sit on the bed Taking a bath or shower purchase things or meals Standing up/sitting on a chair Going up/down stairs Walking around in ward (visiting room or treatment room) Reaching something above your head/ bending down for something Walking with an IV stand Walking on a slippery ground Walking with assistive devices (eg., stick or walker) Walking while tubing on boy (eg., IV, drainage tube) Walking up or down on slope road The average score
After intervention Mean ± SD
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Patients’ self-efficacy of fall prevention Self-efficacy indicates a patient’s belief in their ability to perform and manage specific behaviors, and thus, minimize their risk to improve quality of life. The average patients’ self-efficacy score for fall prevention was 46.05, indicating a moderate level of concern about falling for participants in this study. To the best of our knowledge, this is the first measurement of fall prevention self-efficacy based on responses from hospitalized cancer patients. A similar assessment of self-efficacy of fall prevention was used to evaluate fall risk among the elderly in their home environments. Fall risk scores using this instrument were 33.8 in Taiwan [34], 23.8 in Britain [35] and 22.06 in Australia [36]. Self-efficacy scores in this study were higher, which probably reflects the findings by Yardley et al. [17], who described that the self-efficacy of fall prevention increased in patients with chronic diseases. The FPPP intervention had an impact on cognition, which in turn increased the concerns about fall prevention. Scores for the items ‘getting in/out of bed’ and ‘standing up/sitting on a chair’ increased in the participants who took part in the intervention, representing new knowledge about fall prevention. The bedside is the most common area where falls occur in hospital. Awareness of this fact significantly increased after the intervention. Using scenarios in a question and answer format, instruction was readily assimilated, and patients were eager to participate in the program. Conducting subjective interviews to assess individual fall risk is vital to care planning [33]. Patient-centered instruction based on learning and experience can enhance both autonomy and the sense of responsibility for personal health [29, 37]. This study confirmed that appropriate health education is a useful strategy for fall prevention. 306
Fall incidence in cancer patients The incidence of falls among a matched sample of oncology patients was 19.3% in this study. This finding is higher than the range of 6.8–14.4% reported in an acute care setting [38] and is also higher than the incidence of 6.9% previously reported among advanced cancer patients [12]. Our frequency matched group, with an average age of 49.31 years and consisting of 62.3% men in the oncology unit, had a much higher fall incidence. However, the fall incidence after FPPP was 0 and was statistically significant (P < 0.05). This finding supports the assertion that proper education regarding fall prevention and subsequent application of this knowledge can decrease the incidence of falling [19]. For those inpatients (n ¼ 68) who participated in the study, fall incidence decreased after the intervention. However, the data amassed for the two groups at the two different periods were not subjected to a homogeneity test, which would have reduced the validity of the results. A patient-centered approach, including an evaluation of outcomes that are relevant to patients, would increase the fall prevention knowledge and reduce the incidence of falls in hospital [29, 30, 38]. Linking the elements of fall risk assessments to care planning will ultimately improve patient outcomes. In this study, a simple 20-min intervention significantly improved outcomes in a group at high risk of falls [38]. Although the factors that lead to falls are varied and hard to control [19], this study demonstrate that an intervention such as FPPP could improve fall awareness among patients and reduce the incidence of in-hospital falls.
Limitations There are some limitations in this study. First, the use of self-reported data may have resulted in reporting bias. Second, the intervention was conducted in one hospital, and only 68 patients were involved; therefore, the results cannot be generalized to the broader population. Third, this study was designed to compare differences between two groups at two different periods, and without a homogeneity test, potential mediator or moderator variables cannot be
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careful are reportedly the most common risk-management strategy employed by individuals [30, 33]. Thus, providing information and helping patients to recognize the main risks factors brought about a change in thinking: they became aware of the differences between the hospital and home environment and were more vigilant in preventing falls.
Falling prevention participatory program in oncology patient
Implications for practice Our results show that patients with advanced cancer admitted to hospital had greater knowledge and self-efficacy of fall prevention after the FPPP intervention. Patients displayed better knowledge and concern about falls, and the incidence of falling decreased after the intervention. These findings can be used as an empirical evidence to support the provision of health education to improve care by preventing avoidable falls. Appropriate knowledge about fall prevention in hospital settings must be communicated to the general population. Upon admission, oncology patients should be fully apprised of their fall risk, including the fact that the bedside is the most frequent location for falling in hospital. In addition, the proper use of hospital equipment that can prevent falls needs to be clarified for hospitalized patients. A well-designed health care education intervention can improve the patients’ knowledge and quality of care.
Funding China Medical University, Taiwan, (Contract no: DMR-100-142); National Science Council, Taiwan (Contract no: NSC102-2314-B-039-028-MY2).
Conflict of interest statement None declared. References 1. Taiwan Joint Commission on Hospital Accreditation. 2009. Fall Events. 48: Taiwan Patient Safety Reporting System Annual Report, 2009. (in Chinese).
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Vol.30 no.2 2015 Pages 298–308 Advance Access published 8 December 2014
The effectiveness of a participatory program on fall prevention in oncology patients Li-Chi Huang1,2, Wei-Fen Ma1,2, Tsai-Chung Li3, Yia-Wun Liang4, Li-Yun Tsai2 and Fy-Uan Chang2* School of Nursing, China Medical University, Taiwan, 2Department of Nursing, China Medical University Hospital, No. 2 Yuh-Der Road, Taichung 40447, Taiwan, 3Graduate Institute of Biostatistics, China Medical University, Taichung, Taiwan and 4Department of Senior Citizen Service Management, National Taichung University of Science and Technology, Taichung, Taiwan *Correspondence to: F.-U. Chang. E-mail: [email protected]; [email protected] Received on September 4, 2013; accepted on November 12, 2014
Abstract
Introduction
Falls are known to be one of the most common in patient adverse events. A high incidence of falls was reported on patients with cancer. The purpose of this study was to explore the effect of a participatory program on patient’s knowledge and self-efficacy of fall prevention and fall incidence in an oncology ward. In this quasi-experimental study, 68 participants were recruited at a medical centre in Taiwan. A 20min fall prevention program was given to patients. A questionnaire was used to evaluate the effectiveness of program after on day 3 of intervention. The data of fall incidence rates were collected from hospital record. Fall incidences with and without the program were used to compare the effectiveness of intervention. The patients’ knowledge and self-efficacy of fall prevention are better than after intervention. A statistically significant difference in fall incidence rate was observed with (0.0%) and without (19.3%) the program. Our findings suggest that the fact of the bedside is that the most risk for falling in hospital must be communicated to the hospitalized patients. Educating patients about fall prevention and activities associated with falling increases their awareness of the potential of falling and promoting patient safety.
Patient safety is an important issue in hospitals, and the incidence of patient falls is a distinct indicator of quality health care throughout Taiwan. The Taiwan Joint Commission on Hospital Accreditation (TJCHA) declared that risk factors for inpatient falls must be reduced [1]. According to the TJCHA records, 7805 falls occurred in hospitals in 2009, of which 52% resulted in injuries [1]. One study in the United States that included 315 718 falls between 2006 and 2008 reported that 26.1% of falls resulted in injuries [2]. Falls during hospitalization have resulted in fracture, head trauma and other serious injury [3]. Falls and their sequelae increase medical costs, adding to the financial burden already incurred by the patient’s hospital stay [4, 5]. Falling can lead to increased medication, activity restriction, further decline in physical function, greater risk of future falls and lower quality of life [5]. This highlights the importance of teaching patients how to prevent falls during their hospitalization. Falling is defined as an unexpected drop to the floor or other flat surface (Taiwan Quality Indicator, Taiwan). Falls must be recorded in medical charts and reported by all certified health institutions (Taiwan Quality Indicator, Taiwan). A high risk of falling is associated with gait instability, agitation or confusion, urinary incontinence/frequency, prior
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doi:10.1093/her/cyu072
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1
Falling prevention participatory program in oncology patient sufficient effort to achieve a certain performance level. Moreover, self-efficacy is an important variable that affects patients’ self-care and satisfaction and is observable as a determinant of competence [15–17]. Fall self-efficacy scales were developed to measure confidence in performing activities of daily living without falling in community settings [17–18]. However, no fall efficacy scale is available in the hospital setting. Many fall prevention strategies are derived from the evidence obtained from clinically stable people living in their own homes [19–21]. Several studies have reported modest effects on fall prevention through structured, multifaceted interventions among hospital inpatients [22, 23], geriatric patients [20, 21] and cancer patients [6, 8, 9]. These studies indicate that oncology patients are at a high risk of falling, and interventions must be provided to increase knowledge and prevent falls in this population. However, there is a lack of evidence showing how health education affects falls among cancer patients in oncology departments. An effective fall program is needed that not only provides accurate information but also enhances the patient’s confidence in managing his or her own risk. Thus, we developed a Fall Prevention Participatory Program (FPPP) to address gaps in the knowledge and competency of oncology patients when managing their own fall risk in a hospital setting. This program was empirically evaluated for its effectiveness in changing the knowledge and self-efficacy and fall incidence rate.
Methods Design A quasi-experimental design was used to investigate the effectiveness of FPPP in oncology patients. The study was conducted in two parts. In part I, we implemented a single-group pretest and post-test design using a self-report questionnaire to evaluate the change of patients’ knowledge and self-efficacy of fall prevention. Patients’ knowledge and self-efficacy of fall prevention in hospital were tested on admission (pretest) and on day 3 (post-test); FPPP 299
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history of falls, administration of ‘culprit’ drugs (sedatives/hypnotics), sensory neurological deficits and impaired physical functions such as blurred vision, weak gait, poor cardiovascular function and low hemoglobin [6–9]. In addition, environmental factors may also contribute to the risk of falling [7]. Studies have shown that diagnosis of advanced cancer confers a greater risk of falling than that with other illnesses [6, 8, 9]. Reports show that one in two patients with advanced cancer fall during a 6-month period, due to the nature of treatment and generally longer hospital stays than those in patients with other diseases [8]. Thus, effective intervention to reduce falls is particularly needed in oncological clinical practice. Prevention of inpatient falls is a principal tenet of health policies in medical institutions. Effective fall prevention begins by assessing risk factors and screening high-risk patients [8, 10, 11]. Identifying potential risk factors is the first step in the primary and secondary preventions of injury [8]. Risk factor assessment may heighten the need for vigilance among medical staff, patients and caregivers. Various fall assessment tools, including the STRATIFY and Morse risk-rating scales, are commonly used for measurement and prediction of falls with high sensitivity and specificity [10–12]. Although several fall risk assessment tools are available, no single tool is completely appropriate for every cancer care setting [8]. Once risk factors have been assessed, caregivers and nurses should pay more attention to patients at high risk. An alternative fall prevention strategy is to improve the patient’s self-efficacy. Many patients lose their sense of control over the disease and their lives [13]. Thus, self-efficacy is an important component of success in self-care [13, 14]. Researchers have found that self-efficacy can predict the likelihood of a patient implementing health-related behaviors, when actual behaviors cannot be measured [13–15]. The concept of self-efficacy was developed by Bandura and is defined as an individuals’ confidence in his or her own ability and competence to complete tasks in certain situations [16]. Task completion or abandonment depends on the degree of selfefficacy; people with high self-efficacy expend
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Participants Subjects were recruited through convenience sampling of patients admitted to an oncology ward at a level three medical center in the central district of Taiwan. Patients aged 18 years who were admitted for cancer therapy were invited. Patients were excluded from this study if they were unconscious, had suicidal ideation or intent or had a psychiatric diagnosis. Optimal sample size was achieved using mathematical equations for comparing two density incidence rates in part II of the study [24]. The mean monthly fall incidence was 13% (per 100 patientdays) in the oncology ward in 2010. To detect a fall incidence of 4% (per 100 patient-days; hospitalwide average in 2010) with a difference of ¼ 0.05, 52 subjects were needed to achieve a power of 80% to detect statistically significant differences. The effect was selected when the smallest effect would be important to detect the difference in fall prevention knowledge and self-efficacy before and after the intervention with a difference of ¼ 0.05 (part I of the study). With a sample size of 60, the study had a power of 99% to yield a statistically significant result. We first enrolled 79 hospitalized patients for part I of the study. After undergoing chemotherapy, 19 patients withdrew because of deteriorating medical conditions and an inability to complete the post-test questionnaire. In total, 60 participants completed the pretest and post-test questionnaires, providing a 76% completion rate in the intervention group. In part II, to evaluate the effectiveness of intervention, data of intent-to-treat was included. Thus, a 300
total of 68 participants were in the intervention group by including eight participants who were hospitalized 3 points were considered at a high risk of falling [26]. The second subscale consisted of 20 true/false items regarding the fall prevention knowledge,
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was delivered after the pretest. In part II, to evaluate the effectiveness of intervention, a two-independent group design was used. We analyzed the fall incidence rate of the sample during the FPPP intervention and a matched sample from the period prior to the intervention to compare the effectiveness of the intervention. Fall incidence data were collected from hospital records of observed falls. These data were collected in the same oncology unit from March to May 2010 (no intervention) and 2011 (intervention).
Falling prevention participatory program in oncology patient
including hazardous situations (seven items), awareness of information (nine items) and environmental conditions (four items). The third subscale included 15 items concerning patients’ self-efficacy of fall prevention. These questions were designed to assess the patient’s confidence regarding fall prevention during hospitalization, personal activities of daily living (nine items), and instrumental activities of daily living (six items). Each subscale was developed to be suitable for the hospital environment. Items were scored on a four-point Likert scale from ‘very concerned’ (4) to ‘not at all concerned’ (1). Higher scores indicated better fall prevention knowledge and a higher level of selfefficacy of fall prevention. The instrument’s readability, accuracy and adaptability were adequate, as determined by an expert panel of reviewers and a pilot study among 15 patients. The panel consisted of experts in hospital management, health education, oncology care nursing, nursing administration supervision and statistics (one each). The face validity of the instrument was determined by an expert reviewer
with a Core Values IndexTM estimate of 0.9 [27]. The reliability of the instrument was determined in the pilot study. The internal consistency of the instrument was measured using the Kuder– Richardson Formula 20, resulting in a score of 0.66 in patients’ knowledge of fall prevention. Cronbach’s alpha was 0.95 for patients’ self-efficacy of fall prevention.
Data collection and analysis This study was approved by the Institutional Review Board of the university hospital (DMR-100-038). In part I, each patient was assessed for fall risk at initial encounter. Patients admitted to the oncology ward who met the inclusion criteria were invited to participate in the study and informed consent was obtained. The FPPP intervention was implemented after completing the pretest questionnaire. The post-test questionnaire was conducted on day 3 of hospitalization. In part II, the fall incidence was defined by the incidence density, which was defined as the number of falls divided by the total number of inpatient days 301
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Fig. 1. The process of enrollment and intervention allocation in two groups.
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Results
Table I. Demographic data of two groups for fall incidence evaluation Intervention (n ¼ 68) Variable
n (%)
Age 3). Cancer patients were aged 47.8 years on average, which was much younger than the average of hospitalized cancer patients in other studies [6–8] and is consistent with the notion that aging may not be a risk factor for falling in patients with cancer. It appears that the prevalence of falls is related to factors other than demographics [8]. In this study, a high proportion of medication usage (91.7%) and poor sleep status (83.3%) were revealed as risk factors for falling. However, these results may be subject to selection bias because patients hospitalized for cancer treatment may be more likely to use medication and have disturbed sleep patterns compared with those in patients with other diseases.
Patients’ knowledge of fall prevention In this study, the impact of FPPP was evaluated among hospitalized cancer patients and participation increased the fall prevention knowledge in the cohort of patients. Our results are consistent with those of other studies of fall prevention, in which knowledge was increased through a health program for the elderly [22, 23]. 303
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Variable
L.-C. Huang et al. Table III. The comparison of participant’s knowledge of fall prevention before and after intervention (N ¼ 60)
Variable
*P < 0.05, **P < 0.01, ***P < 0.001 McNemar test. % indicates the correctness rate. b F indicates false answer of question c T indicates true answer of the question. a
304
After intervention correctness n(%)a
P-value
Tb T
55 (91.7) 58 (96.7)
60 (100) 58 (96.7)
0.063 1.0
F
45 (75.0)
54 (90.0)
0.035
T
59 (98.3)
60 (100)
1.0
T
60 (100)
60 (100)
1.0
F
27 (45.0)
42 (70.0)
0.001**
T
58 (96.7)
59 (98.3)
1.0
T
57 (95.0)
59 (98.3)
0.50
T F T Fc
54 5 59 28
60 44 60 41
0.310 0.000** 1.0 0.002**
F
33 (55.0)
54 (90.0)
0.000***
T
56 (93.3)
60 (100)
0.125
T
55 (91.7)
60 (100)
0.063
T
59 (98.3)
60 (100)
1.0
F
14 (23.3)
34 (56.7)
0.000***
F
28 (46.7)
49 (81.7)
0.000***
F
19 (31.7)
46 (76.7)
0.000***
F
18 (30.0)
46 (76.7)
0.000***
70.7 14.12 ± 2.156
88.8 17.77 ± 1.854
0.000***
(100) (8.3) (98.3) (46.7)
(100) (73.0) (100) (68.3)
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Fall may cause bleeding, endangering life Patients in hospitalized over age 65 likely to falls than other group because of poor eye vision and joint activity According to the statistics of falls, the more prone to falls are women By taking blood pressure medicine, tranquilizers, sleeping pills diuretics, hypoglycemic, analgesics, anti-histamine medicine, patients are prone to fall because medicines may cause dizziness, vertigo, hypotension Medication or disease could cause postural hypotension. It should adopt a progressive out of bed, sit in the bedside 5–10 min, wait until no dizziness or discomfort, then get out of bed When I want to get up for toilet at midnight. I can get up out of bed and slowly walk to the toilet even if no company or my family were asleep My body may become weak in hospitalized. It should be slowly movement while get up or out of bed It is better to have a sedative hypnotics after the toilet In order to avoid the fall risk after taking medicine Using sedative hypnotics is easy to have dizziness The location most prone to fall in the hospital is the bathroom Aisle or bedside cannot put sundries for preventing falls because The wet floor in the room or toilet, I can wait until cleaners to wipe it dry For the convenience of getting out of bed, it doesn’t need the bed rail. Only need the bed rail while sleeping in the night time Standing up after the toilet is easy to have postural hypotension and led to fall Don’t leave the ward during the injection of painkillers for preventing fall When you want to get out of bed but feel dizzy and no family around. It’s better to use the calling bell, asking nurses for help The caregiver can leave while patient is sleep; and get back as soon as possible The moveable IV stand can be placed at the end of the bed for preventing fall The commode chairs should be placed in the bathroom for maintaining a tidy environment The slippers should be placed outside the bathroom when taking a shower because slipper would get wet that cause fall Average correctness percentage Mean ± SD
Correct Answer
Before intervention correctness n (%)a
Falling prevention participatory program in oncology patient Table IV. The comparison of participants’ self-efficacy before and after intervention (N ¼ 60) Before intervention Mean ± SD
Variables
P value
3.13 ± 0.98 2.65 ± 1.04 2.90 ± 0.90 2.93 ± 0.90 3.32 ± 0.95 2.87 ± 1.08 2.70 ± 0.94 3.23 ± 0.85 2.68 ± 1.11
3.13 ± 0.93 2.83 ± 0.98 3.13 ± 0.85 3.25 ± 0.90 3.43 ± 0.79 2.90 ± 0.97 3.05 ± 0.93 3.33 ± 0.88 2.88 ± 0.96
1.000 0.101 0.008** 0.007** 0.211 0.788 0.007** 0.307 0.135
3.05 ± 1.10
3.22 ± 0.96
0.214
3.13 ± 0.93 3.48 ± 0.73 3.25 ± 0.91
3.30 ± 0.85 3.62 ± 0.61 3.42 ± 0.79
0.115 0.117 0.115
3.37 ± 0.80
3.32 ± 0.81
0.635
3.35 ± 0.82 46.05 ± (11.58)
3.40 ± 0.83 48.27 ± (10.72)
0.635 0.043*
*P < 0.05, **P < 0.01, paired t test.
Table V. The comparison of fall incidence between the patients with/without the intervention Intervention (2011)
No Intervention (2010)
Number of total inpatient day
Frequency of falls
Incidence of falls (per 100 day)
Number of total inpatient day
Frequency of falls
Incidence of falls (per 100 day)
Z value
1009
0
0.00
1557
3
19.3
1.98*
The pretest answers were most frequently incorrect for question #10, ‘The location (at which a patient is) most prone to falls in the hospital is the bathroom’ (8.3%). However, scores for this question noticeably increased after the intervention (73%). According to the TJCHA’s patient safety report [1], most fall events during hospitalization occur at the bedside (27.6%), whereas with the second most common location being the bathroom (19.5%). After hospital admission, changes in body function and effects of medical treatment may affect body balance while getting up from a bed or chair [28]. Thus, the fact that most falls occur at the bedside, rather than in the bathroom, should be considered
for hospitalized patients, particularly those with cancer. Differences between home and hospital environments as well as in the patient’s physical condition may increase the fall risk among hospitalized patients. Research has shown that this can be reduced by implementing multifactorial fall prevention strategies that include fall risk assessments, door/bed fall risk alerts, environmental modifications and additional assistance with toileting [23, 29–32]. Through education, risk factor assessment, discussion and implementation of FPPP, patients were able to strengthen their knowledge of fall risk and participate in their own risk management. Patients being more 305
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Being in toilet Getting dressed/undressed Getting in/out of bed Getting up to sit on the bed Taking a bath or shower purchase things or meals Standing up/sitting on a chair Going up/down stairs Walking around in ward (visiting room or treatment room) Reaching something above your head/ bending down for something Walking with an IV stand Walking on a slippery ground Walking with assistive devices (eg., stick or walker) Walking while tubing on boy (eg., IV, drainage tube) Walking up or down on slope road The average score
After intervention Mean ± SD
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Patients’ self-efficacy of fall prevention Self-efficacy indicates a patient’s belief in their ability to perform and manage specific behaviors, and thus, minimize their risk to improve quality of life. The average patients’ self-efficacy score for fall prevention was 46.05, indicating a moderate level of concern about falling for participants in this study. To the best of our knowledge, this is the first measurement of fall prevention self-efficacy based on responses from hospitalized cancer patients. A similar assessment of self-efficacy of fall prevention was used to evaluate fall risk among the elderly in their home environments. Fall risk scores using this instrument were 33.8 in Taiwan [34], 23.8 in Britain [35] and 22.06 in Australia [36]. Self-efficacy scores in this study were higher, which probably reflects the findings by Yardley et al. [17], who described that the self-efficacy of fall prevention increased in patients with chronic diseases. The FPPP intervention had an impact on cognition, which in turn increased the concerns about fall prevention. Scores for the items ‘getting in/out of bed’ and ‘standing up/sitting on a chair’ increased in the participants who took part in the intervention, representing new knowledge about fall prevention. The bedside is the most common area where falls occur in hospital. Awareness of this fact significantly increased after the intervention. Using scenarios in a question and answer format, instruction was readily assimilated, and patients were eager to participate in the program. Conducting subjective interviews to assess individual fall risk is vital to care planning [33]. Patient-centered instruction based on learning and experience can enhance both autonomy and the sense of responsibility for personal health [29, 37]. This study confirmed that appropriate health education is a useful strategy for fall prevention. 306
Fall incidence in cancer patients The incidence of falls among a matched sample of oncology patients was 19.3% in this study. This finding is higher than the range of 6.8–14.4% reported in an acute care setting [38] and is also higher than the incidence of 6.9% previously reported among advanced cancer patients [12]. Our frequency matched group, with an average age of 49.31 years and consisting of 62.3% men in the oncology unit, had a much higher fall incidence. However, the fall incidence after FPPP was 0 and was statistically significant (P < 0.05). This finding supports the assertion that proper education regarding fall prevention and subsequent application of this knowledge can decrease the incidence of falling [19]. For those inpatients (n ¼ 68) who participated in the study, fall incidence decreased after the intervention. However, the data amassed for the two groups at the two different periods were not subjected to a homogeneity test, which would have reduced the validity of the results. A patient-centered approach, including an evaluation of outcomes that are relevant to patients, would increase the fall prevention knowledge and reduce the incidence of falls in hospital [29, 30, 38]. Linking the elements of fall risk assessments to care planning will ultimately improve patient outcomes. In this study, a simple 20-min intervention significantly improved outcomes in a group at high risk of falls [38]. Although the factors that lead to falls are varied and hard to control [19], this study demonstrate that an intervention such as FPPP could improve fall awareness among patients and reduce the incidence of in-hospital falls.
Limitations There are some limitations in this study. First, the use of self-reported data may have resulted in reporting bias. Second, the intervention was conducted in one hospital, and only 68 patients were involved; therefore, the results cannot be generalized to the broader population. Third, this study was designed to compare differences between two groups at two different periods, and without a homogeneity test, potential mediator or moderator variables cannot be
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careful are reportedly the most common risk-management strategy employed by individuals [30, 33]. Thus, providing information and helping patients to recognize the main risks factors brought about a change in thinking: they became aware of the differences between the hospital and home environment and were more vigilant in preventing falls.
Falling prevention participatory program in oncology patient
Implications for practice Our results show that patients with advanced cancer admitted to hospital had greater knowledge and self-efficacy of fall prevention after the FPPP intervention. Patients displayed better knowledge and concern about falls, and the incidence of falling decreased after the intervention. These findings can be used as an empirical evidence to support the provision of health education to improve care by preventing avoidable falls. Appropriate knowledge about fall prevention in hospital settings must be communicated to the general population. Upon admission, oncology patients should be fully apprised of their fall risk, including the fact that the bedside is the most frequent location for falling in hospital. In addition, the proper use of hospital equipment that can prevent falls needs to be clarified for hospitalized patients. A well-designed health care education intervention can improve the patients’ knowledge and quality of care.
Funding China Medical University, Taiwan, (Contract no: DMR-100-142); National Science Council, Taiwan (Contract no: NSC102-2314-B-039-028-MY2).
Conflict of interest statement None declared. References 1. Taiwan Joint Commission on Hospital Accreditation. 2009. Fall Events. 48: Taiwan Patient Safety Reporting System Annual Report, 2009. (in Chinese).
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