Reducing the Risk of Recidivism in Saudi Arabia

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Abstract

The problem of falls is a significant one, and it is especially common among older adults, which is why the Center for Disease Control’s (CDC) Stopping Elderly Accidents, Deaths, and Injuries (STEADI) intervention was developed. At an outpatient clinic in Florida, the intervention is not used, which is why this evidence-based option is going to be tested. The purpose this quantitative quasi-experimental project is to determine if or to what degree the implementation of the CDC STEADI program would impact out-of-clinic falls reported by the caregiver when compared to current practice among people aged 65 and older who run high risks of falling and are cared for by a caregiver while visiting an outpatient clinic in Florida over 4 weeks. Orem’s self-care deficit theory and the IOWA implementation model will be used as the theoretical foundations to guide the project. Data on falls and near falls were measured in adults aged 65 years and older, (n=45). A paired t-test showed a statistically significant improvement in falls (M=-XX; SD=XX; p=XX) and an improvement in near falls (M= XX; SD=1.41XX; p=XX). Based on the results, the recommendation was to continue the program at the project or a larger facility for a longer period of time.

Background of the Project

The present quality improvement project focuses on older patient falls and their prevention measures; specifically, the introduction of educational means of fall prevention among caregivers is going to be considered. Numerous older individuals are subject to falls, making it a significant topic in the health care industry (Durgun et al., 2021; Shahrbanian et al., 2021). The proposed intervention is the implementation of the Stopping Elderly Accidents, Deaths, and Injuries (STEADI) program by the Centers for Disease Control and Prevention (CDC), which, when applied to healthcare professionals, offers a set of tools meant to educate patients and caregivers on how to prevent falls. As a result, it is intended to implement the STEADI program within a specific outpatient clinic with the goal of equipping its providers with the means of educating caregivers on fall prevention in older adults.

Quality improvement gaps and the importance of the issue can be used to explain why the project is worth conducting. According to the Centers for Disease Control and Prevention (CDC) (2019), older patients suffer from falls, which reduces their quality of life and increases healthcare expenses (Durgun et al., 2021; Shahrbanian et al., 2021). This problem can be prevented, and the research field offers multiple interventions, one of which is the STEADI program, which incorporates the above-named educational materials that are supposed to be provided by the healthcare workers to patients and (or) caregivers. In terms of being dedicated to a solution to a major healthcare issue, the presented project is worthwhile.

Over the past years, STEADI has been considered by the relevant research articles (Casey et al., 2017; Eckstrom et al., 2017; Johnston & Reome-Nedlik, 2020; Lee, 2017; Lohman et al., 2017; Mark, 2019; Mark & Loomis, 2017; Nithman & Vincenzo, 2019; Sarmiento & Lee, 2017; Vincenzo & Patton, 2019; Urban et al., 2020). STEADI is a well-established and reliable tool, which makes its implementation appropriate for a quality improvement project (Eckstrom et al., 2017; Johnston & Reome-Nedlik, 2020; Lee, 2017; Lohman et al., 2017; Mark, 2019). The STEADI approach’s application is a topical area in that more research is being introduced in the recent years (Casey et al., 2017; Eckstrom et al., 2017; Johnston & Reome-Nedlik, 2020; Lee, 2017; Lohman et al., 2017). As a result, the introduction of STEADI within a specific setting that does not use it appears to be a suitable topic for a quality improvement project.

It should be highlighted that there is a significant gap in investigating educational materials for fall prevention when it comes to caregivers, even though this group has an impact on fall prevention (Schoberer et al., 2016; Xu et al., 2019). Still, there is some evidence to view the intervention that targets caregivers rather than patients as potentially helpful (Black et al., 2018; Schoberer et al., 2016; Xu et al., 2019). The focus of the project does not take away from it being evidence-based but instead makes conducting it especially important from the perspective of contributing to the growing field of knowledge. Since falls are a major concern among the older population, and older persons often live with caregivers, it is reasonable to investigate the impact of this intervention.

The given quality improvement project follows specific guidelines that are represented in its particular structure. Background information will be presented to understand the scope of the problem. This section will be followed by theoretical foundations, including problem statement, purpose, clinical question, advancing scientific knowledge, and the project’s significance. Furthermore, Chapter 1 will comment on methodology, project design, terms used, and limitations. After that, all critical points will be summarized. Consequently, Chapter 1 will explain why it is necessary to address the problem of patient falls and how it is possible to identify the effectiveness of the STEADI intervention.

Background of the Project

Patient falls have always been a significant issue in the health care industry. According to the CDC (2019), “more than one out of four people of 65 and older fall each year” (p. 1). In turn, Perrot et al. (2019) explained that multiple settings are forced to deal with this issue. This situation justifies the fact that numerous scientific studies address the problem and offer possible solutions to it, which include patient and caregiver education (Durgun et al., 2021; Shahrbanian et al., 2021). For this project, specifically caregiver education is important, which is one of the options, as well as specific needs of people providing care to those experiencing a risk of falls (Black et al., 2018; Mamani et al., 2019; Schoberer et al., 2016; Xu et al., 2019). However, it should be highlighted that patient and caregiver education can be applied together, which is the case of the project’s site.

At the site, which is a small outpatient clinic in Florida, the issue of falls is among the common concerns for healthcare professionals, and interventions to prevent falls are employed with the goal of limiting them to as few incidents as possible. There are no data to suggest that the issue is particularly acute at the site; the same can be said about falls outside of the clinic reported by patients or family members, which are the focus of the project. According to the currently available information, specifically among patients over 65, any number of falls outside of the clinic had been reported at the rate of 21-23% for each of the years 2017-2019, which is lower than is reported as an average by CDC (2019). However, the number is still fairly large, and falls have been identified and officially recognized as a problem since the site’s institution, and the healthcare providers, particularly nurses, dedicate time to offering education on falls to either patients or caregivers of patients in case they are the ones who are expected to modify the environment of their homes. Not every patient or caregiver receives the education; the need is determined on a per-case basis, and no scheduled follow-ups are offered to ensure that the information is remembered and remains effective.

The clinic does not use CDC’s STEADI materials for that purpose, which calls for an introduction of the latter both due it being supported by evidence and the need for a uniform approach to the issue (Casey et al., 2017; Eckstrom et al., 2017; Johnston & Reome-Nedlik, 2020; Lee, 2017; Lohman et al., 2017; Mark, 2019; Mark & Loomis, 2017; Nithman & Vincenzo, 2019; Sarmiento & Lee, 2017; Vincenzo & Patton, 2019; Urban et al., 2020). The fact that STEADI has materials meant for caregivers is especially important for the project and since it is one of caregivers’ needs (Black et al., 2018; Mamani et al., 2019; Schoberer et al., 2016; Xu et al., 2019). STEADI materials are regularly adapted and reviewed, and they are offered for download from the CDC website for everybody, including healthcare providers. The openness of the source makes it easier to use for this project.

Both caregiver and patient education programs are one of many interventions that can be effective in preventing patient falls, and numerous research articles prove this claim. For example, education is referred to in the studies by Hill et al. (2017), Perrot et al. (2019), as well as others (Frith, 2017; Lyons & Hall, 2016; Ott, 2018; Shim & Kim, 2019; Ximenes et al., 2019; Zhao et al., 2019). In the proposed project, specifically caregiver education is important or, to be more precise, the tools for providers to improve caregiver knowledge. The intended outcome is the reduction in falls in the older population who visit the project’s site. Therefore, by offering the providers STEADI for caregivers, the well-being of the older patients is meant to be improved.

Problem Statement

It was not known if or to what degree the implementation of the CDC’s STEADI program (educational materials available to providers meant for older patient caregivers) would impact falls when compared to standard fall prevention interventions among patients aged 65 and older in an outpatient clinic. Thus, the project attempts to identify whether the STEADI program can reduce the prevalence of patient falls by affecting the knowledge of caregivers through educational materials offered by providers. If yes, the project will assess the effectiveness of this intervention compared to the consequences of implementing usual standards of care, contributing to the literature on the topic (Eckstrom et al., 2017; Johnston & Reome-Nedlik, 2020; Lee, 2017; Lohman et al., 2017; Mark, 2019). The results will not be conclusive, but they will offer additional insights on the topic while introducing an evidence-based intervention into a healthcare setting (Eckstrom et al., 2017; Johnston & Reome-Nedlik, 2020).

It is worth mentioning that the problem significantly affects a specific population. It refers to patients of an outpatient clinic since they appear in unusual conditions that subject them to potential threats; specifically, it involves patients appearing outside of a tightly controlled environment (the clinic) while still running rather high risks of falling as a result of numerous causes (Dhalwani et al., 2017; Gomez et al., 2017; Haines et al., 2015; Kiyoshi-Teo et al., 2017; Kuhirunyaratn et al., 2019; Mota de Sousa et al., 2017; Yoo et al., 2015). Furthermore, the focus is placed on people of 65 years old and older. It is so because these many of these individuals’ health conditions are deteriorated because of natural processes (Durgun et al., 2021; Shahrbanian et al., 2021), which subjects them to more falls (Dhalwani et al., 2017; Gomez et al., 2017; Haines et al., 2015; Kiyoshi-Teo et al., 2017; Kuhirunyaratn et al., 2019; Mota de Sousa et al., 2017; Yoo et al., 2015). Every fall can have more dangerous consequences for older people than for younger patients (Durgun et al., 2021; Shahrbanian et al., 2021).

That is why it is rational to look for ways how to address the problem under consideration. The given project tries to cope with this task and offer valuable information. The project results can contribute to solving the problem. It is so because the analysis of the STEADI’s program can confirm that this intervention is effective in protecting older patients from falls, which would suggest that caregiver education is important for patient health (Eckstrom et al., 2017; Johnston & Reome-Nedlik, 2020; Lee, 2017; Lohman et al., 2017; Mark, 2019). Overall, the goal of the project is to contribute to the wealth of data on a particular evidence-based intervention while implementing it at a site that recognizes the importance of the issue of falls. The main positive outcome of this project being successful would consist of the providers of the site having a new set of tools for caregiver education. Finally, some attention will be brought to caregiver education, which is also a positive outcome given their need for education (Mamani et al., 2019).

Purpose of the Project

The purpose of this quantitative quasi-experimental project is to determine if or to what degree the implementation of the CDC STEADI program would impact falls reported by the caregiver when compared to current practice among people aged 65 and older who run high risks of falling and are cared for by a caregiver while visiting an outpatient clinic in Florida over 4 weeks. The STEADI program (independent variable) will be defined as the educational component of the STEADI intervention. Falls as routinely reported by caregivers to providers during visits (dependent variable) will be defined as the instances of patient collapse. The population is specifically Florida (south of the state) outpatients who are older people (over 65) cared for by a caregiver and at risk of falls as defined by STEADI.

This purpose indicates that the project will try to improve the health outcomes of older patients in one outpatient clinic in Florida. By analyzing the STEADI program, the project will show whether it is possible to reduce the prevalence of patient falls with the help of this caregiver-oriented evidence-based intervention, contributing to the literature on the topic, which is scarce for caregivers (Schoberer et al., 2016; Xu et al., 2019). The findings will also demonstrate whether other clinics and health care settings should draw their attention to caregiver education to address the problem under analysis, which is especially important since the topic is underrepresented in the modern literature compared to, for example, patient education (Frith, 2017; Lyons & Hall, 2016; Ott, 2018; Shim & Kim, 2019; Ximenes et al., 2019; Zhao et al., 2019). The findings, therefore, will have immediate value for the patients while also contributing some data to the field of study, as well as providing the healthcare workers of the site with new tools and signaling to other healthcare workers about the opportunities of CDC’s STEADI.

Clinical Question

To what degree does the implementation of the CDC’s STEADI program impact the rates of falls among patients aged 65 and older when compared to standard care in an outpatient clinic in Florida over four weeks? The CDC’s STEADI program will be used as an evidence-based intervention. The standard fall prevention does not use STEADI as its means of assessing the risks of falling and educating patients or caregivers on the topic. The population includes patients over 65 in the outpatient clinic. The selected timeframe is the most feasible one for the project.

The clinical question implies different variables The STEADI program is an independent variable, meaning that its implementation needs no measurement. Falls is the dependent variable, which denotes that it is necessary to measure them. The project participants disclose these events on a caregiver-report basis, and a ratio is identified. It is essential to calculate the number of events per 100 individuals (in percentages), which is already done by the site (Newcastle upon Tyne Hospitals, n.d.; Washington Health Care Association, n.d.). The predictive statement is that there might be a statistically significant difference between the ratio of falls as reported by caregivers prior to and after the intervention (per 100 people).

Advancing Scientific Knowledge

The project will result in some improvements concerning population health outcomes. the project findings will demonstrate whether it is adequate to rely on the STEADI program in preventing patient falls. In case of positive results, this advancement will be a small step forward in a line of current quality improvement projects, which demonstrate that STEADI can be used effectively in practice (Eckstrom et al., 2017; Johnston & Reome-Nedlik, 2020; Lee, 2017; Lohman et al., 2017; Mark, 2019). In this case, it will be necessary to identify ways to strengthen this intervention’s effect. Additionally, the project will be contributing to the covering of a research gap associated with the caregiver education as a method of fall prevention; there are very few sources on that specific topic despite the rather extensive amounts of sources on the education of patients, and it should be highlighted that the caregivers do have educational needs (Meyer et al., 2016; Perrot et al., 2019). Overall, the project can contribute to the improvement of practice in the studied clinic and advance knowledge in an understudied field.

This project proposal focuses on Orem’s (1985) self-care theory. Younas (2017) stipulates that worsened health outcomes are often the result of self-care deficit. This concept implies that a person lacks sufficient knowledge or desire to take care of themselves. Consequently, the program has the potential to enhance people’s knowledge to improve their health outcomes, which can lead to the illustration of the theory under consideration, as well as its ability to predict and explain relevant phenomena.

Additionally, the IOWA model should be mentioned. It provides the means of implementing a new intervention of any kind (Collaborative et al., 2017), and the presented project does require a form of intervention implementation. Specifically, the CDC’s STEADI will be implemented within the project’s site using the IOWA model (its testing stage). If the project is fully successful and demonstrates positive outcomes, the site may choose to use the rest of the IOWA model to ensure the full integration of STEADI into its practice. The two models do not really interact, but they do not cause issues or conflict either. They will be used for their respective purposes, and their strong and weak points will be discussed below.

Significance of the Project

A quality improvement project gap explains the project’s importance. There are empirical studies that would support the effectiveness of the STEADI program (Eckstrom et al., 2017; Johnston & Reome-Nedlik, 2020; Lee, 2017; Lohman et al., 2017; Mark, 2019), which makes it an evidence-based intervention that is currently studied very extensively. It is a topical area that can benefit from additional exploration, especially in the form of a quality improvement project that implements this evidence-based intervention within a site that does not use it. Caregiver education generally receives little attention in research (Meyer et al., 2016; Perrot et al., 2019), but it is a fact that caregivers have educational needs, which are often overlooked and which need to be taken into account (Black et al., 2018; Mamani et al., 2019; Schoberer et al., 2016; Xu et al., 2019). The given project might contribute to the current literature on the topic, and it will fit into the literature on the topics of the STEADI program and educational interventions for fall prevention aimed at caregivers. The results will not be able to offer a conclusion on whether it is reasonable to conduct additional studies to assess the educational intervention’s effectiveness, but they will move the scientific debate into that direction.

The project is also significant because it might generate crucial theoretical implications. It relates to the connection between patient falls and Orem’s self-care theory. In particular, the project will reveal whether eliminating the self-care deficit through an educational approach to caregivers can lead to fewer patient falls in an outpatient setting. It means that a relationship between patient outcomes and the self-care deficit will be analyzed. The use of the IOWA model is common in nursing projects, but still, another demonstration of its usability could be helpful.

Finally, it is reasonable to comment on the project’s practical implications. The results will be beneficial for practitioners because they will understand whether it is useful to use this fall prevention method. The project’s results will influence a way of health care delivery within the stated setting. Attention to educational needs of caregivers will be brought. In the long run, the project might contribute to the improvement of the whole medical industry since it tries to improve older patients’ health outcomes. By demonstrating the ability of STEADI to improve the well-being of patients, the relevant literature on the topic will be supported (Eckstrom et al., 2017; Johnston & Reome-Nedlik, 2020; Lee, 2017; Lohman et al., 2017; Mark, 2019), and as a result, the project will be able to highlight and promote the use of STEADI in outpatient settings. Thus, the project’s main ability is the application of STEADI within a specific setting and potentially the demonstration of its usefulness overall.

Rationale for Methodology

The proposed quality improvement project tries to identify the extent to which the specific intervention influences the prevalence of patient falls. It means that it will be necessary to work with figures and make appropriate calculations to identify whether the proposed solution is significant, which requires a quantitative methodology. Creswell and Creswell (2017) explain that this methodology type is necessary when there is a need to test for a relationship between different variables. Furthermore, Rutberg and Bouikidis (2018) stipulate that the reasons to choose this methodology are “if a lack of quality improvement project exists on a particular topic, if there are unanswered quality improvement project questions” (p. 210). As for the given project, the quality improvement project gap and the unanswered clinical questions are present, denoting that the methodology is correctly chosen.

In addition to that, a quantitative methodology seems the best option because other variants, including qualitative and mixed methods, are not suitable. A qualitative methodology is used when it is necessary to explore a problem that is not well understood (Rutberg & Bouikidis, 2018). Quality improvement projects tend to organize semi-structured interviews to allow participants to disclose their feelings and attitudes to the problem under analysis. Qualitative investigation would not be able to respond to the stated clinical questions, which seek to establish relationships between variables, although it can be helpful in other circumstances (Polit & Beck, 2017). A mixed methodology combines the features of the previous two, which is why it is not suitable either: it incorporates qualitative approaches which would not be helpful in this instance. Mixed methodology is used in those cases when scientists want to calculate statistical indicators and identify participants’ feelings (Rutberg & Bouikidis, 2018). Finally, Polit and Beck (2017) admit that quantitative methods are more feasible since they require less time to answer clinical questions in comparison with qualitative and mixed approaches. In conclusion, it is possible to mention that the given project’s methodology is chosen according to the problem statement, clinical questions, and purpose.

Nature of the Project Design

This project follows a quasi-experimental design to reach the purpose and answer the clinical question. This design includes the intervention (STEADI program) and one group observed to determine the falls that it experiences before and after the intervention. Such studies are suitable to identify a relationship between an intervention and its outcomes (Polit & Beck, 2017; Rockers et al., 2017). Furthermore, this design is appropriate to assess interventions’ effectiveness while also being relatively easy and quick to implement (compared to, for example, an experiment) (Polit & Beck, 2017). That is why a quasi-experimental design is the best approach for the given project as compared to other options: it is more feasible than an experiment and implies fewer ethical concerns than it, but it is also sufficiently capable of responding to the clinical questions, which makes it more appropriate than, for example, post-test project only.

The given project does not have an extended sample because it considers a Florida outpatient clinic that is not large. That is why a sample size includes 45 caregivers based on a GPower analysis. The inclusion criteria are the absence of language and mental impairment barriers for the caregiver, the status of a caregiver, the age (65 years and older) of the person cared for, as well as their high fall risks as previously identified by the provider. At the same time, language barriers and mental impairment are the caregiver exclusion criteria. The language barriers are worth mentioning because the clinic typically serves the Spanish community; STEADI materials are predominantly in English, which can affect the possibility of recruiting people who do not have a good command of the English language.

The project will use one group (pre- and post-test design), all the caregivers of which will be provided with STEADI education by the providers (Polit & Beck, 2017). The caregivers will also report the falls of the people they care for during four weeks. The baseline data will consist of the previously reported falls for the same patients as long as there is reported data; additionally, the average rate of falls in the clinic will be taken into account. Polit and Beck (2017) explain that pre- and post-test data are sufficient to assess the effectiveness of education. Consequently, the report will use caregivers’ self-reports to identify whether the STEADI education is useful in reducing falls.

Definition of Terms

This section will explain terms, variables, and other specific terms that may be unknown to a layperson.

Caregivers

In this project, specifically informal caregivers are considered. Informal caregivers are the people who provide care to other people (usually disabled, with impairments or older) while not having a formal education on the activity. In other words, healthcare providers are formal caregivers, and informal caregivers do not have similar education, which forms their need for additional learning for improved patient outcomes (Black et al., 2018; Mamani et al., 2019; Schoberer et al., 2016; Xu et al., 2019).

Falls

Falls are completed events that occur when patients have collapsed (Hill et al., 2015). These events imply adverse health consequences but can be preventable. Various factors, including health conditions, external factors, the lack of education, and others, can make patients collapse. In the context of this quality improvement project, falls are a dependent variable.

Self-Care

The concept of self-care refers to a person’s ability and desire to take care of themselves (Younas, 2017). Self-care deficit can result in the fact that individuals neglect their health condition and well-being. The current project considers Orem’s self-care theory and its relation to the occurrence of falls.

STEADI

The CDC (2019) program meant to prevent falls in older patients, which offers providers with important tools. For this project, the educational tools for caregivers and patients are important. STEADI guides providers on how to educate those two groups, and the implementation of the program has been studied comprehensively (Eckstrom et al., 2017; Johnston & Reome-Nedlik, 2020; Lee, 2017; Lohman et al., 2017; Mark, 2019), which makes it an evidence-based solution.

Assumptions, Limitations, Delimitations

The given quality improvement project implies one assumption that deserves attention.

• First, the participants’ interest in the project is an underlying assumption. This fact denotes that these people will be willing to undergo the educational intervention, actually apply it in their life and report the data. Research shows that the rates of adhering to interventions vary, but they tend to be rather high; specifically for STEADI, they are estimated to be at around 75% (Vincenzo & Patton, 2019).

It is also reasonable to comment on the project’s limitations.

1. On the one hand, a small sample size of 45 participants is objectively a weakness, but it should be sufficient for the specified methodology based on GPower analysis.
2. Furthermore, the fact that the participants will only represent one clinic is important (Polit & Beck, 2017).
3. It is not assumed that the caregivers’ self-reports are truthful and honest. The project does take it into account that people can lie, hide information or simply forget it (Polit & Beck, 2017), which is why the self-reported nature of the project’s data is a limitation.
4. The short timeframe of four weeks is admittedly a limitation (Polit & Beck, 2017), but it is explained by feasibility considerations.

Finally, a delimitation also deserves specific attention in the given project.

• This work focuses on older patients because they are more subject, compared to younger individuals, to falls.

Summary and Organization of the Remainder of the Project

Patient falls at healthcare facilities and outside of them are a significant issue in the health care industry. According to the CDC (2019), numerous individuals older than 65 years old are subject to this problem, making it necessary to find an effective intervention. Perrot et al. (2019) stipulate that education is a suitable approach, and a few scientific articles assess the impact of the STEADI educational program. This fact determines the significance and purpose of the project, which focuses on the falls outside of the clinics.

An appropriate quality improvement project piece is necessary to proceed to study the effect of CDC’s STEADI program. That is why a quantitative quasi-experimental study of 45 participants with the pre- and post-intervention group seems suitable for the current project (Rutberg & Bouikidis, 2018; Polit & Beck, 2017). Orem’s (1985) self-care theory and the IOWA model will guide it. Over four weeks, the project’s findings will lead to significant theoretical and practical advancements to the health care industry through the investigation of the effects of an evidence-based intervention. The small sample will be a major limitation, as well as the timeframe.

Since the introduction to the project is completed, it is reasonable to proceed to reviewing the literature in detail. Thus, Chapter 2 will present a detailed background and literature section and comment on the project’s theoretical foundations. Chapter 3 will focus on purpose, clinical question, and methodology to cover all these details in precision. Chapter 4 will describe the results of data analysis, which is necessary to understand how the project will reach and interpret its results. Chapter 5 will offer a conclusion along with recommendations based on the project.

Literature Review

This quality improvement project focuses on fall prevention in older populations, especially the education of caregivers based on the STEADI program (Centers for Disease Control and Prevention [CDC], 2017; 2019). This section is a literature review, which will present the results of a systematic review of the literature on the topic of falls education, as well as some findings of non-systematic reviews of the literature on falls in general.

Thus, the project involved two sections; the first one was based on systematically reviewing all the literature on the topic of education-based fall prevention that was published within the past 5 years in peer-reviewed journals found in large healthcare databases, including MEDLINE, CINAHL, and PubMed. The decision to limit the literature to recent articles was made to ensure the most pertinent information about the up-to-date approaches to the issue was included. The named databases are among the sources that are most often employed in healthcare research (Polit & Beck, 2017).

The second section involved finding predominantly recent articles on the topic of falls, including fall prevalence, fall prevention and fall education, as well as caregiver involvement in fall prevention. This literature was required because the systematic review produced a limited number of sources, and expanding the years of source search helped to include more information. Additionally, some seminal works were incorporated (in particular, for the theoretical frameworks of the project), but in the majority of cases, the project looked into recent literature.

For the systematic part of the literature review, inclusion criteria were English language, availability and published date (past 5 years). The keywords included “fall prevention,” “education,” “older patients.” Articles could be excluded for not being relevant to the project.

This chapter will be structured in the following way. It will include themes and subthemes, which will be supported by several sources. The first theme is the importance of falls, which is highlighted in all the reviewed literature but will be exemplified through a limited number of sources. The second theme is the possibility of reducing falls, which is illustrated through empirical recent and less recent literature, including the articles by Carlucci et al.’s (2018), Hill et al. (2015), Jie and Deng (2019), Meyer et al. (2016), Nakagami-Yamaguchi et al. (2016), Ueda et al. (2017), and some others. Some conflicting data will be presented as well (Hill et al., 2019), and it will be demonstrated that significantly more research on the topic is required, especially since recent sources on the topic are rather scarce, and certain subtopics (especially the education of caregivers) are rarely considered. It will be highlighted that the presented literature supports the proposed methodology of the current project, although it can be used to showcase and legitimize different approaches, especially quantitative ones.

Additionally, the topic of the theoretical framework of the project will be covered with a focus on the conceptual framework supported by the seminal work by Orem (1985), as well as the change model supported by the literature on the IOWA model. The use of both models will be justified, and their combined usability will also be considered. The next section will be focused on that exact topic.

Background

The present project does not really uncover a starting point of the studying of the problem of falls in or outside of healthcare settings, but it shows that it has been identified extensively; it is currently recognized as a serious issue, especially among older patients (those above 65 years old) (Durgun et al., 2021; Shahrbanian et al., 2021). Falls can cause injury, resulting in additional healthcare expenses and reduced quality of life, and the issue is associated with multiple factors that can direct efforts aimed at preventing falls (Dhalwani et al., 2017; Gomez et al., 2017; Haines et al., 2015; Kiyoshi-Teo et al., 2017; Kuhirunyaratn et al., 2019; Mota de Sousa et al., 2017; Yoo et al., 2015). Research shows that educational solutions meant for patients, caregivers and professional caregivers are an option (Chang et al., 2019; Cho & Jang, 2020; Frith, 2017; Lyons & Hall, 2016; Ott, 2018; Radecki et al., 2018; Shim & Kim, 2019; Turner et al., 2020; Ximenes et al., 2019; Zhao et al., 2019), but specifically the interventions for patients are rarely researched, and those for informal caregivers are almost never studied. The need for them is established, though, as patients and caregivers ask for additional information on falls (Schoberer et al., 2016; Xu et al., 2019). Therefore, the topic of caregiver education in fall prevention is a clear research gap with few recent sources even mentioning it without trying to contribute. The present project will attempt to contribute by introducing STEADI interventions with a focus on family caregivers.

Theoretical Foundations

Orem’s (1985) self-care theory is used by this project. The concepts of self-care and self-care deficits have explained and justified educational interventions for patients (Younas, 2017), which explains its choice for the current project. Since it is focused on the education of patients and caretakers, Orem’s (1985) theory might be able to frame the clinical question and assist in understanding the mechanism behind the work of the project’s intervention.

Orem’s (1985) general idea is that nursing is the act of assisting someone with self-care, which, in turn, is the ability to take care of oneself, meaning the ability to maintain one’s well-being. To be a nurse, a person needs to have the knowledge and training required to understand and assist other people with their self-care. Humans are the object of nursing, as a result, and the subjects are nurses. The environment is also taken into account, including physical and social aspects. Orem’s (1985) view of health as soundness is slightly outdated, but it took into consideration both the health of individuals and groups, which is helpful for the present project, which considers the unit of patients and caretakers. A self-care deficit implies that a person cannot ensure effective care of themselves for any reason, which often includes a deficit of resources, but might also incorporate a variety of factors, including demographics (for example, age), cultural and social factors, and environmental factors (for example, access to healthcare) (Orem, 1985). One of the primary reasons that justifies the present project is the lack of knowledge. The same can be said about the lack of knowledge in caring for another person. Improved knowledge should reduce a self-care deficit in the participants, providing them with improved means for self-care, which, in turn, should lessen the negative outcomes of self-care deficits (falls). Thus, the theory explains the variables and the reason for the possible relationship between them.

Self-care is a complex concept, which incorporates universal requisites (something that is required for a person to be able to perform self-care, including the intakes of air, water, food, excretion, rest, interaction, development and management of hazards), as well as the requisites that become important when a person is in the state of “health deviation.” Teaching another person how to self-care and ensure the fulfilment of all these requisites is one of the methods of helping a person to self-care (Orem, 1985).

It is important that for Orem’s (1985) theory, the interactions between humans are critical. According to the theory, humans form connections for the sake of their well-being and to exchange the means of self-care, as well as organize the care for the people who cannot take care of themselves. This perception of self-care and human attempts to provide care to those who cannot perform it is also helpful in understanding the variables of the project, in particular, the ideas of exchanging knowledge for improved self-care and the concept of caretakers. Caretakers are the people assigned by the society to perform caring for people with self-care deficits, and knowledge exchange is one of the instruments they can employ.

In terms of the specific change of the project, the IOWA model (Collaborative et al., 2017) is going to be employed. It is aligned with the project’s question since the latter presupposes implementing an intervention. Regarding the current advancements on the project, the issue has been identified, and the literature on the topic has been collected, with a solution found and researched. What remains now is to implement the change with a small number of participants, after which the results of the project will be analyzed. It is not planned to include a greater number of people or actual implementation within the specified setting into this project because its timeframe is not sufficient, but if the pilot of the change, which is this study, is successful, future research may consider the topic in greater detail. The IOWA model is very helpful in guiding evidence-based practice, and with its emphasis on research, including investigation of the existing literature and the assessment of the outcomes of the current project, it has been employed in many similar projects (Speroni et al., 2020).

In terms of combining the two ideas, the models are not in any conflict. The project treats Orem’s (1985) model as its conceptual framework and IOWA model as its change framework. The former allows conceptualizing different aspects of the project and justifies it; the latter exists for the more technical aspects, which refer mostly to the process of implementing the intervention, or, rather, piloting it, if IOWA terms are used. Therefore, it is possible to employ both models and appreciate their respective advantages in relation to the different aspects of the project.

Review of the Literature

The present section will consider the themes and subthemes present in the literature that was found with the help of a systematic literature review, as well as a non-systematic review on the topic of educational interventions for falls and falls overall respectively. The approach consisted of reviewing the major healthcare databases according to Polit and Beck (2017) and finding the literature that could be found to test or discuss an intervention, especially STEADI, although all other information-based interventions regardless of their application (to patients, nurses or caregivers) were considered as well. The articles were only included if they were in English; also, the goal was to exhaust the literature on educational fall interventions within the past 5 years, but since the project has been going on for a while and since certain literature from other years proved to be very helpful, some additional older literature was included. Thus, the literature includes a systematic review of the sources in English in the past 5 years dedicated to educational fall interventions, as well as some older sources and general fall sources.

The Major Problem of Falls Requires Interventions

All the reviewed literature indicates that the problem of falls in different settings, including home (out-of-clinic falls), is a major one, which requires attention and solutions based on the relevant risk factors and results in numerous and often complex interventions, including those that focus on education (Bargmann & Brundett, 2020; Dhalwani et al., 2017; Gomez et al., 2017; Haines et al., 2015; Kiyoshi-Teo et al., 2017; Kuhirunyaratn et al., 2019; Mota de Sousa et al., 2017; Yoo et al., 2015). This theme focuses on the nature of falls as the primary justification for the project. It employs predominantly recent sources with a few justified exceptions, and it exists to justify the fact that educational interventions exist.

Falls and Reduced Quality of Life

First and foremost, falls are dangerous and capable of diminishing a person’s quality of life (Durgun et al., 2021; Shahrbanian et al., 2021). Multiple quantitative studies demonstrate that falls can cause issues, based on the fact that they are associated with injuries. This information is critical in ensuring that the project is justified.

Burns et al. (2020) presents a statistics study based on the Vital Statistics and Behavioral Risk Factor Surveillance System data, which demonstrates the importance of falls for older men and women in the US. Specifically, the authors highlight the importance of falls (713/1000 in 2018), fall injury (171/1000 in 2018), and fall deaths (increased 16% between 2012 and 2018 to 64/1000, which was a statistically significant increase). Additionally, the authors found an increase in the fall injuries among men, who, however, report fewer falls than women. In summary, the article offers very useful, if broad, findings on the topic of falls in older adults in the US. There are no findings in this article regarding Florida, but the US rates are still important, and they show the rates and changes in rates of falls, which justify the present project as one dedicated to an important issue that is growing in importance.

Gazibara et al. (2017) carried out an epidemiological study, which aimed to determine the frequency of falls in older people (n=354 older Serbians), as well as a number of other characteristics of falls that would be useful for fall analysis and prevention. The sample consisted of people older than 65, and they came from one community health center. The main method of data collecting was detailed interviews along with the Falls Efficacy Scale. The frequency of falls amounted to 15.8%, and half of them occurred during walking; moreover, almost half of all falls were injurious (49.1%). The most common injuries sustained included head hematomas, as well as “soft tissues contusions”; the majority of the people experiencing falls were female and had a fear of falling (Gazibara et al., 2017, p. 215). It should be pointed out that the article is not very generalizable because it only studied the population of one Serbian health center, but still, the findings provide an idea about the characteristics of falls that make them dangerous.

Hill et al. (2015) carried out a randomized controlled trial (RCT) with 3,606 inpatients from Australia to determine the effectiveness of a fall prevention intervention, finding that roughly 30% of the falls were injurious. The authors justified their attention by highlighting the fact that falls were very common events in hospital settings and established the aim of examining the effectiveness of a specific program meant to reduce falls in patients through the education of both patients and staff. The project was multicenter, which improves the generalizability of the findings; it also took place over the course of 50 weeks, which makes it approach a longitudinal research method. The allocation to the control and intervention groups was random (as is required for an RCT), and their comparison showed that no significant differences between the groups could be found. The only important difference was that the number of falls (based on a patient-days fall registration system) was smaller in the intervention group, which implied that the rates of falls were reduced in that group and that the program was effective. The project only involved Australian patients, but the number of patients was large, and they came from different centers, which improves the generalizability of the results. Furthermore, the use of RCT as a research design improves generalizability as well. Overall, this is a very solid source that assists in improved understanding of the mechanisms behind reducing falls in hospital settings. In addition, the article showed that the number of injurious falls was also reduced by the intervention.

Moreover, in an effort of making the project more longitudinal, Hill et al. (2019) performed a follow-up to an RCT to determine the effects of a fall intervention on post-discharge falls, finding that more than half of all the falls were injurious. The goal of the project was to determine the effects of an educational program on post-discharge falls, which the authors explained by the fact that after hospital discharge, older people tend to experience falls. The methodology was an RCT once again, and the settings were Australian; the duration of the study involved 6 months of following the participants. The intervention presupposed using a video and a workbook, as well as a discussion. This time, only 382 participants were involved (over 65 years of age), with 188 people in the control group, assigned randomly. The results suggested that significant differences between the groups in terms of fall rates did not exist, but falls were reported by the participants, and half of them were injurious (49.7%). The program was tested with a rather small number of participants coming from one country; as a result, the findings are not very generalizable. Still, the findings regarding the number of injurious falls seem to be in line with the rest of the cited research, although, admittedly, more investigation is required to determine the effectiveness of this specific program and other programs. This source can be considered counter to the rest of the articles on fall prevention interventions in that it does not find a statistically significant difference between the two groups. However, these findings should only be applied to the specific intervention used by Hill et al. (2019).

To summarize, the literature on the topic suggests that falls, especially in older adults, are likely to be injurious and reduce the quality of life of patients, which is why it is important to address the issue. This subtheme includes a very important source which contradicts the findings that will soon be discussed, and it also uses an older source that was included because of its connection with the critical contradicting source. Overall, the literature that is presented in future themes supports the exact same idea: all the authors who write on the topic in qualitative or quantitative sources demonstrate that falls are a significant issue that should be addressed.

Complex Causes of Falls

Falls are associated with very numerous factors, and they are especially commonly related to a combination of factors working in concert. Both qualitative and quantitative studies provide the relevant information, suggesting that knowledge might be among the factors of interest (Dhalwani et al., 2017; Gomez et al., 2017; Haines et al., 2015; Kiyoshi-Teo et al., 2017; Kuhirunyaratn et al., 2019; Mota de Sousa et al., 2017; Yoo et al., 2015). In this section, the potential risk factors of falling in elderly patients are going to be reviewed with a focus on psychological factors and other ones that can be affected by education.

Hopewell et al. (2018) in a Cochrane systematic review, included 62 trials with almost 20,000 community-dwelling older adults, most of them women. The research involved multifactorial interventions that typically incorporated exercise, technological interventions, psychological ones, as well as medication review, and multiple component interventions, that typically included exercise and education. The authors concluded that either option could be effective, and importantly, all of them addressed diverse fall risk factors, including medication, frailty, instability, gait and balance problems, as well as problems with vision and the presence of a number of chronic diseases; additionally, environmental factors were identified, for example, insufficiently secure rails, or slippery surfaces and bad footwear. Typically, an interaction of factors was relevant, and additionally, knowledge of risk factors was shown to be effective in reducing falls. It is also noteworthy that among the studied outcomes were fall rates, number of people experiencing falls, number of people sustaining several falls and/or fall-related injuries, as well as number of people experiencing hospital admission and/or requiring medical attention as a result of their fall. Overall, this study is very helpful in contextualizing the current project, with its quality being Cochrane-level. However, the limitations of the project are noteworthy: specifically, the authors highlight the fact that many of the projects have issues with quality, which may have affected the quality of the results of their review. Additionally, not many countries are represented in the project, but still, the findings are particularly important.

Pua et al. (2017) studied a connection between falls efficacy, as well as postural balance, and fall risks in the elderly, and they recruited 247 adults, who were visiting a specific emergency department. The outcomes were fall rates and gait speed, as well as falls efficacy and postural balance. The participants were observed for 6 months. Based on their findings (which were determined with the help of a multivariable proportional odds analysis, with confounding variables taken into account), the authors were able to conclude that falls efficacy affected the relationship between balance and fall risk, and low falls efficacy was also associated with reduced gait speed. In other words, falls efficacy was considered among the modifiable (for example, through education) features that could reduce the risk of falls in older adults. Admittedly, the sample was not very large, and it was mostly drawn from one location, which may have affected the outcomes. However, the analysis was very rigorous, with confounding variables taken into account, and the methodology was that of a prospective cohort study, which guarantees a high level of quality. Overall, the findings can be used to highlight the complexity of the interactions of risk factors for falls, as well as to demonstrate that education which targets specific risk factors can be useful.

Mota de Sousa et al. (2017) used the approach of a systematic literature review to identify risk factors for falls in older adults who reside in a community. The authors highlighted that they identified 50 risk factors, of which only 38 were listed on the Taxonomy of the NANDA International. The authors explicitly meant to update that taxonomy. The following key risks were identified: physiological factors (most typically, difficulties with seeing, walking, balancing, as well as pains, lowered strength and mobility and a number of specific illnesses or conditions, for instance, urinary urgency), environmental ones (for example, the absence of grab bars or anti-slip materials in strategic areas), pharmacological agents (various medications, especially polymedication), cognitive factors (different reasons for changes in cognitive function), psychological factors (for instance, the fear of falling and depression), socioeconomic factors (in particular, low education), and personal factors (most commonly, age and gender). This is a very comprehensive, nurse-oriented review that provides findings based on 62 sources, all of which have their own limitations but can still be used due to the author’s focus on primary sources with predominantly cohort or correlational and descriptive studies, as well as a few RCTs and quasi-experiments. It is noteworthy that the evidence was gathered from all over the world, but, admittedly, the US and Australia were the most well-represented ones. Overall, the review provides some very good grounds for understanding the causes of falls, and it can be used to contextualize this project, as well as its intention of considering and adjusting the psychological factors of falling.

Schoene et al. (2019) provide a systematic review of specifically the issue of the fear of falling. The authors investigated the association between this factor and the quality of life in older people. A total of thirty studies were identified with roughly 29,000 people, the majority of them women, and through a literature review, the authors demonstrated that fear of falling did appear to be in an association with quality of life, lowering it, while falls themselves did not have a similarly profound effect on quality of life. Fear of falling is commonly associated with falls as one of the relevant risks (Perrot et al., 2019), but this study exists to specifically demonstrate that fear of falling in itself is a major issue that deserves to be addressed. Falls were not shown to have an impact on fear of falling. In the end, the authors highlight the importance of interventions that address fear of falling, which would be expected to affect the risks of falling while also improving the quality of life in older patients.

In summary, the number of sources on the topic of the causes of falls is substantial, and it suggests that there are diverse causes, several of which can act simultaneously. As a result, the primary intervention that the sources, which are very high-quality, suggest is a holistic intervention. However, admittedly, the intervention that targets education would also be appropriate based on the presented findings.

Addressing Falls through Information

Falls need to be addressed, and they often need to be addressed through information (Chang et al., 2019; Cho & Jang, 2020; Radecki et al., 2018; Turner et al., 2020). There exist sufficient amounts of information on education-based interventions, which assist through the development of understanding in participants. This subtheme is critical in justifying the project.

Mamani et al. (2019), in an interview-based study (n=97; Brazil), investigated caregiver practices and found that their knowledge on the topic was superficial. In fact, almost half of the participants exhibited little to no knowledge on the topic, and only one fourth of them practiced different methods of fall prevention. Despite using qualitative methods, the project was focused on quantitative analysis, and it showed that more knowledge and improved attitudes toward fall prevention could be developed within the population. The authors concluded that insufficient knowledge and inappropriate perceptions of fall prevention might have been among the reasons for the low percentage of practicing fall prevention methods, but their study was not correlational, so they could not assert that based on their data. The project had a small sample of only Brazilian people; however, the research on caregivers is so limited that these findings provide at least some information on the topic.

Singh et al. (2020) evaluated the state of fall prevention at Canadian facilities, and while this topic is not directly connected to the topic of community-dwelling adults, it still demonstrates interesting conclusions about the educational component of fall prevention. The project studied a number of specific facilities, and it used the documentation to report the results, finding that pre-fall policies and procedures were intelligence-focused. To be more specific, they included understanding what a fall meant, establishing risks assessments and, eventually, fall prevention approaches, which incorporated environmental and educational components. Overall, the authors concluded that a lot of similarities were found between the different facilities, but a need for more evidence-informed approaches was required. In future articles, direct evidence of the usefulness of education-based interventions will be introduced, but here, it is important to state that educational interventions are already being used, which makes them evidence-based practice.

Similar to Mamani et al. (2019), Lim et al. (2018) prepared an interview-based study (n=100; patients from Singapore) that looked into patient fall experiences and uncovered multiple negative attitudes that could increase patient risks and might need unlearning. It should be pointed out that the Lim et al. (2018) study was qualitative, not quantitative, and it uncovered several key themes. For one, many of the participants appeared apathetic and uncaring about falls, in which they showed the perception of the inevitability of falls, as well as considering them less important than having hygiene issues. Furthermore, the participants blamed themselves for falls, did not want to “impose” on nurses, and were prone to overestimate their abilities, all of which resulted in falls. They also experienced difficulties with remembering fall-related advice. The participants of the study are not representative of any specific population, although most of them were male and over 60 years old. Additionally, the sample was relatively large for a qualitative research but not enough for generalizations. Overall, the research is not generalizable, but it provides some information about the possible specifics of fall experiences, including the attitudes that need unlearning and the fact that more attention needs to be paid to teaching fall prevention.

The fact that falls are a major concern justifies the proposed project (Müller et al., 2019). Research into the causes of falls is important for their prevention. As can be seen from the qualitative studies, patients and caregivers recognize the need for education as well, and while there are limitations to qualitative research, in terms of the needs of participants that are subjective, they are capable of producing relevant data. Since the voices of patients and caregivers are important to consider, the presented literature is critical for understanding the issue.

Educational Interventions Work

Educational interventions work, which is a conclusion made after their scientific investigation (Frith, 2017; Lyons & Hall, 2016; Ott, 2018; Shim & Kim, 2019; Ximenes et al., 2019; Zhao et al., 2019). The investigation is based on a number of different outcomes, some of which will be used in the current project. Additionally, it is important that there are aspects of educational interventions that are not studied very extensively. That includes caregiver education (Schoberer et al., 2016; Xu et al., 2019).

Educational Interventions and Positive Outcomes

Educational interventions work (Frith, 2017; Lyons & Hall, 2016; Ott, 2018; Shim & Kim, 2019; Ximenes et al., 2019; Zhao et al., 2019), although that is a simplistic statement. It might be more accurate to state that a lot of educational interventions for falls appear to be having positive outcomes specified by the relevant literature. However, it is also important to remember the work by Hill et al. (2019), which suggests that different interventions might have different levels of effectiveness. This section will present the findings related to educational interventions that do appear to be working.

Perrot et al. (2019) carried out an RCT of a complex fall prevention intervention (n=30), and they found that it reduced the fear of falling. It is important that the intervention was not just education; it was augmented with physical activities. However, the RCT was carried out specifically to compare the education program with physical activities against physical activity alone, which means that it was the educational program that made the difference between the intervention and control groups. Another issue is that the project had a very small sample, with only thirty people involved, most of them women. The final issue was significant differences between the control and intervention group pre-test. The assignment was random, though, which increased the quality of the project and allowed to call it an RCT. The participants were specifically older adults who had fallen at least once in the year prior to the project, and it used the Timed Up and Go test, the Tinetti test, and the Falls Efficacy Scale, all of which are accepted methods. The findings suggested multiple outcomes, but the most important one for the purposes of this project is that patient education was shown to affect the fear of falling in a positive way (by reducing it). More research with a bigger sample would be required, but the project still offers some insight into the effects that training can do in terms of fall prevention.

Ueda et al. (2017) conducted a pilot RCT to test an educational fall prevention program (n=51), and it was effective in reducing fall rates. To be more specific, the program was meant for older orthopedic patients who had experienced at least one fall in the year preceding the project, and it was based on tailored interventions (educational programs) that incorporated floor plans. The sample size was very small for an RCT, but it should be pointed out that the project was a pilot study. Even with the small sample, it was obvious that the intervention group had fewer falls and near-falls, but still, the limitations of the sample are crucial, as well as the fact that the project employed an innovative and never-before tested program. More research is definitely required to make conclusions on the topic.

Carlucci et al.’s (2018) quasi-experimental research (n=215) showed that the intervention, which was studied in the project, improved falls efficacy and functional reach. To clarify, the intervention incorporated “joyful movement,” which is a complex intervention, incorporating education, psychological intervention and retraining of biomechanics. Only one group of older adults was involved in the project, with only 86 who provided feedback and only 102 who completed all the assessments before and after the intervention. Still, the results suggested that the intervention improved both the mobility and falls efficacy of the participants. It should be highlighted that the project incorporated both educational and other elements, which may have affected the outcomes of the study; furthermore, the sample is admittedly small and drawn from one facility. Still, the research clearly suggests that there are benefits to an intervention with an educational component, which is relevant for the present project. The authors also recommend more research on the topic to determine the effects of the program on fall rates.

Ott (2018) focused on community-dwelling patients, which makes the article very suitable for the project. It was a pilot study meant to investigate an educational session and its effect on knowledge, fall prevention behavior and falls. The design was quasi-experimental, which is helpful for the project, but the sample was very small (only 8 participants completed all activities related to the project), which made the tracking of falls difficult. In the end, the authors could only report one fall in the group, which was not enough for statistical analysis, but fall knowledge and prevention behaviors were both demonstrated to increase after the intervention. Overall, the article is very similar to the current project design-wise, and it also provides some information on the ability of educational interventions improve fall knowledge and prevention.

Kiyoshi-Teo et al. (2019) developed a multimethod research that focused on Veteran inpatient fall prevention recommendations and the ways in which they were implemented based on the Plan-Do-Study-Act cycle. Using the fall rates as their outcome, as well as multiple qualitative and quantitative methods, the authors studied two units within one healthcare system (Portland). The use of fall rates can be considered a recommendation for the project on selecting an appropriate outcome. As for the findings, it is particularly relevant for the project that despite the carrying out of relevant educational interventions, which were mostly connected to communicating information on the topic, the patient participants reported a lack of knowledge on falls. From this perspective, it is apparent that there are more and less effective methods of education, and simple communication of information might not be very effective.

Kuhirunyaratn et al. (2019) focused on urban elderly, which makes the article especially relevant for the project. The aim consisted of studying the effects of an education program, and the settings were urban Thailand. The study was quasi-experimental in nature, with 2 different communities involved; two groups were formed with roughly 100 people in each, all of them over 60. They were all registered at one healthcare unit, and the intervention group was subjected to an educational buddy intervention. The pre-experimental fall risks were slightly smaller for the intervention group, but the intervention helped to further decrease it to a statistically significant level. The findings imply that educational interventions can affect fall risks through medicine usage and other factors, which is a helpful finding for the present project.

Lyons and Hall (2016) focused on Latin America and the Caribbean, which may have limited the applicability of the article to the project, but which also shows that the issue of falls is spread worldwide. Furthermore, the article focuses on community-dwelling older adults, which is aligned with the project’s purpose. The goal of the article was to determine the feasibility of an educational intervention implementation meant to prevent falls in Grenada. The sample of the article was small (62 older people), but it shows that older people in Grenada may be interested in learning more about falls and require falls knowledge, which further supports the idea that educational interventions are a helpful and empowering option of fall prevention.

Ferreira et al. (2019) aimed to construct a fall prevention nursing process to be applied to the elderly with Parkinson’s disease. Immediately it is obvious that the target population is rather specific and different from the target population of this project. However, it is clear that both projects aimed to study the older population (over 65), which brings them close. Only nine older people with the disease were involved, and through interviews and workshops, they helped to produce two games and one educational booklet meant for fall prevention. The authors highlighted the fact of empowerment of the patients, as well as the improvement of their ability to exercise self-care with the help of the specified new interventions. This article is very much in line with the present project, particularly from the perspectives of improving self-care. It also introduces the ways in which caregivers, specifically formal caregivers, can assist patients with fall prevention. However, the population of the article is specific, and while the approach toward the development of the materials can be used outside of the article, the materials themselves have not been tested in terms of their effectiveness. Thus, the article has its limitations, but it shows that educational materials can be developed in ways that empower the target population.

To summarize, there exists sufficient research on the topic to suggest that different educational interventions for fall prevention work. Admittedly, it should be highlighted that the studies typically have small samples or otherwise limited samples, which are also used to test individual interventions. It is rare that one and the same intervention is tested several times. In this light, the work by Hill et all. (2019) is especially important, which is particularly true because it contradicts the rest of the evidence that suggests the usefulness of educational interventions or interventions with educational components (see below). Overall, it can be suggested that more research is required, especially dedicated to one particular intervention. Additionally, it is clear that different methods of establishing intervention effectiveness can be discovered, and the next subtheme is going to discuss this topic in detail.

Methods of Establishing Intervention Effectiveness

Effectiveness of prevention interventions can be established with the help of fall numbers, likelihood, frequency, and so on. Overall, there are a lot of valid methods of determining the quality of an intervention. In this section, some quantitative options will be presented; qualitative ones are outside of the realm of this project because it is quantitative.

Nakagami-Yamaguchi et al. (2016) conducted a pre- and post-test study, in which an animation movie-based prevention method reduced fall frequency and likelihood. The animation was supposed to provide education, which explains the relevance of the study for this project. The study was a pilot one, and it involved both patients and caregivers, which is why this not very recent study was included in the review. However, the project mostly implied nurses as caregivers, which makes it less relevant. Still, the research showed a clear need for educational intervention, with only 30% of the patients understanding the instructions on nurse interaction in terms of fall prevention before the intervention. Furthermore, the findings implied that the 269 patients who had been involved and 304 nurses who had been involved managed to reduce the patient falls to 8.6% from over 15%, which proved to be statistically significant. Furthermore, the likelihood of falls decreased in older patients in a statistically significant way. Overall, the animation proved to be an effective educational tool, and it was specifically more effective for older patients. The study was a pilot one, which explained its limited sample. More research on the topic may be required for additional conclusions.

Dykes et al. (2017) studied falls in acute hospitalization facilities (two of them located in the US), with a focus on an intervention called TIPS (Tailoring Interventions for Patient Safety) and its effects on mean fall rate and injury fall rate. The goal was to test the intervention, which can be considered a clinic decision support tool, and the findings showed that one of the facilities showed significant improvements in both desired outcomes, while the other one only showed improvements in one of them. The study’s strong feature is that it had tracked the compliance of the intervention, but other confounding variables were not considered in this pilot implementation project. More research is clearly required for conclusive statements, especially research in different settings. Still, the project clearly shows that certain measures of falls can be used in the research for fall prevention interventions.

Jie and Deng (2019) tested a fall education (n=178 female patients with osteoporosis) in a pre- and post-test study, which showed a reduction in fall risks and fall likelihood. The topic was rather specific in that the authors focused on osteoporosis patients receiving zoledronic acid, which was explained by a high rate of falling in the population, as well as the negative outcomes associated with falls in the population (specifically, morbidity and mortality). The project involved controls and random assignment to the respective groups (86 intervention cases with a fall prevention education at the time of zoledronic acid administration, as well as a telephone follow-up and another session a month later). The data were collected with the help of a survey before the intervention and after it (one year later). The project has a relatively small sample, and it only recruited female patients with osteoporosis, which limits the findings’ applicability, but still, the results imply that it is possible to reduce fall risks with the help of a fall prevention education.

Bargmann and Brundett (2020) report the findings of a practice project meant to test an intervention bundle for fall preventions with two educational elements (out of five), including daily education of patients and an educational handout. Other elements included patient risk assessment, ensuring the carrying out of previously established fall prevention strategies, and a “safety agreement” with the patients meant to facilitate their interactions with nurses. The fall rate decreased significantly (by a half), and in addition to that, the authors highlighted an increase in staff compliance with fall prevention strategies. They indicated issues with staff turnover as an obstacle to the project but pointed out that communication between the nurses and patients was of utmost importance. The findings suggest that interventions with an educational component can be helpful and that fall rates can be used to assess such interventions and their success.

Shim et al. (2019) carried out a quasi-experiment aimed to investigate the effect of fall prevention education in older patients. The project had an experimental and control group, both about 30 people, which is a small sample as the authors highlight. It still allowed for the use of parametric tests meant to compare the fall knowledge and fall prevention behavior in patients. The intervention consisted of an educational DVD, as well as leaflets; they demonstrated improved scores in both parameters. The information about falls in either group was not provided. The authors highlight that the desired outcomes were achieved with the help of this complex education system, which implies that it can be further researched. From the perspective of the current project, the article is relevant methodology-wise, as well as in terms of demonstrating the effects of educational fall prevention interventions.

In summary, there are a lot of sources which can be used to help direct a new project on the topic of educational fall prevention interventions. It is especially true since they are sufficiently diverse, with different approaches to measuring the same variables. Overall, this literature assisted in producing the methodology for the present project.

STEADI Studies

The STEADI intervention has been studied and written about in professional literature (Casey et al., 2017; Eckstrom et al., 2017; Johnston & Reome-Nedlik, 2020; Lee, 2017; Lohman et al., 2017; Mark, 2019; Mark & Loomis, 2017; Nithman & Vincenzo, 2019; Sarmiento & Lee, 2017; Vincenzo & Patton, 2019; Urban et al., 2020). However, not all the projects are relevant for the current project. In fact, none of them considers the educational component of STEADI from the perspective of caregiver education. The following projects can be used for gaining some information about the intervention.

Eckstrom et al. (2017) incorporated STEADI into a clinic’s routine. The tools that were used to that end included EHR, training, as well as workflow tools. Three-fourth of the providers were involved, and they screened more than a half of the patients (773) throughout six months, most of which required and, therefore, received STEADI interventions. The authors concluded that the screening burden was reduced by STEADI, although the number of patients considered high-risk increased as a result. The only intervention that was not carried out often was the reduction in the medications that affect fall rates. Overall, the project provides an example of STEADI implementation, which will be used during this project’s attempt as well.

Vincenzo and Patton (2019) aimed to determine the adherence to STEADI among older patients. They performed a set of semi-structured interviews, showing that only half of the forty participants who fully participated in the study followed the STEADI recommendations after 6 months, and only about three-fourth remembered any recommendations. Additionally, 32% of them fell, and out of these people, more than half did not follow STEADI recommendations at all. Overall, the authors unearthed an important issue of long-term STEADI effects. While the project will not be able to track long-term effects, this issue will inform STEADI implementation.

Casey et al. (2017) carried out a study meant to apply STEADI in one specific clinic with the help of the Kotter framework. Over 400 people were screened during the entire project, and the researchers reported that the successful implementation needed relevant EHR tools, as well as a workflow that would incorporate STEADI, and appropriate leadership. The researchers describe the project as successful, but there is no direct assessment of STEADI in the project, which was not its aim. Therefore, more research on the topic is required.

Taylor et al. (2019) focused on using STEADI through an interprofessional education approach. The justification for the research consisted of highlighting the importance of being trained in working with older adults and fall prevention for healthcare providers. The article involved healthcare students, faculty and older adults (all below 32 people) with the goal of training the former and involving the latter in carrying out a STEADI intervention. Student knowledge increased in a statistically significant way, especially with regards to fall prevention and STEADI, showing that the latter could be used for geriatric health education. The sample size is not very large, but it can still be used to demonstrate STEADI utility, especially in fall prevention education.

Wongrakpanich et al. (2019) carried out a quality improvement project meant to investigate the STOP-FALLING checklist, which was developed specifically for one long-term care facility. The project used a pre- and post-test approach (three months before and after checklist introduction) with a rather small sample of 32 patients. The findings showed an improvement in fall rates and staff satisfaction, a reduction in falls with minor and major injuries, and a reduction in frequent fallers. The approach of the project could be considered a pilot study, which is why the small sample is acceptable, but the authors propose further advancing the study of the checklist. This article is relevant for the present project because it shows the ways in which a fall prevention intervention can be studied while also highlighting the importance of tools like the ones included into STEADI in fall prevention.

Urban et al. (2020) commented on the lack of the literature on fall prevention in primary care and proceeded to introduce the STEADI program (with a focus on its education materials) in a primary care clinic. The staff involved included 29 people, and they were educated on the topic of falls with the help of the STEADI materials, which resulted in a statistically significant increase in the mean knowledge score before and after the test, although no statistically significant difference between the control group and education group in terms of STEADI use was found. The authors concluded that the use of STEADI is recommended from the perspective of knowledge improvement, but the project was not successful in implementing the toolkit. The article can be used to demonstrate the value of STEADI kits, but it does not provide directions on how to implement them.

Lohman et al. (2017) focused on investigating STEADI and its validity and adaptability. The article involved using the National Health and Aging Trends Study to gather information about a large, representative sample of older adults (over 7000 people). The information was used to apply the STEADI toolkit to the adults and determine its ability to predict outcomes, including falls and mortality. The findings suggested that the STEADI toolkit was valid in that it was able to predict adverse outcomes.

Mark and Loomis (2017) focused on the implementation of STEADI toolkit into clinical practice. The article is theoretical, and it consists of a literature review and a commentary on STEADI tools. It concludes that the main issue that STEADI implementation is likely to involve is the actual utilization of the toolkit, which is evidenced to be effective based on the literature review. The authors highlight that STEADI is capable of preventing falls and saving funds, but they recommend more research on the validity and reliability of the toolkit. Overall, the article can be used to support the use of STEADI and introduce information about it into the project.

Johnston et al. (2019) implemented STEADI to determine its impact on a primary care system. The article is especially relevant for the project since it was carried out in the US and since it involved outpatient clinics (n=14). The number of people involved exceeded 12000 of people older than 64, which is very large for a study that only involved a part of New York as its setting. The STEADI was used to develop Fall Plan of Care for a group of participants who were at fall of risks; a control group with fall risks and no plan of care was introduced, as well as a group that was classified as having no risk of falls. The plan of care based on STEADI was capable of reducing the likelihood of fall-related hospitalizations in a statistically significant way compared to the group with no plan of care; in fact, the people with a plan of care showed similar likelihood of fall-related hospitalization as people who were classified as having no risk of falling. Therefore, the STEADI toolkit was shown to be effective in preventing fall-related hospitalization, which implies that it was also helpful in reducing the likelihood of falls. Naturally, the article described a study that took place only in one region of the US, which implies that the results for Florida might be different, but still, this article offers a lot of evidence for the present project.

In summary, the presented literature suggests that STEADI is a valid and helpful tool, and even though there is little investigation of its effectiveness, research suggests that it is very capable of bringing along positive outcomes in terms of fall prevention. Very recent sources show that the issue is topical, but the findings also suggest that more research is required. Overall, the literature can be considered justifying the current project by indicating that the intervention is an evidence-based solution.

Caregivers and Fall Prevention

Caregivers are rarely considered in fall prevention, especially informal and domestic caregivers, which makes every recent article on the topic critical and relevant for the current project (Schoberer et al., 2016; Xu et al., 2019). However, there is also a limited number of relevant sources. A number of relatively recent articles have been identified that considered caregivers, although their contribution to the topic is not equal.

Xu et al. (2019) provided a qualitative project meant to develop a fall prevention program for stroke survivors based on the survivors’ own opinions (9 people), as well as caregivers and helpers (8 people). Through interviews and thematic analysis, the project determined that both survivors and their caregivers would benefit from fall prevention interventions, and they determined that caregivers were often overprotective of the survivors they cared for. These findings suggest that caregivers are an important element of fall prevention, but it is merely a qualitative study, which means that its level of evidence is not very high (Polit & Beck, 2017). Overall, this study is only included because there is little to no information on caregivers.

Schoberer et al. (2016) is a relatively outdated source, but it provides a qualitative study of the perspectives of patients and caregivers, including family caregivers, regarding an educational fall prevention intervention (specifically, a fall prevention brochure). The participants (25 residents, 12 family caregivers and 14 nurses) reported that they were interested in learning about fall risks, as well as methods of recovering after one, and family members also wanted to know more about strategies meant to prevent falls. This information suggests that education for caregivers would have been very helpful, which justifies the present project.

Hoffman et al. (2018) presented an analysis of different categories of caregivers from the perspectives of their association with falls and injurious falls. The findings suggest that different levels formal and informal care are associated with a reduced risk of falls, as well as injurious falls (although to a smaller degree). The total sample was almost 8000 people, 20% of them with caregivers. The project also took place over several years, which further boosts its quality. The sample does have the limitation of being only applicable to the US, but still, the project suggests that caregivers are important for fall prevention and that the amount of effort their offer along with their qualifications can improve the quality of that effect.

Nakagami-Yamaguchi et al. (2016) carried out a study that was aimed at developing an educational movie as a method of fall prevention. The evaluation involved implementing the movie in a pre- and post-test fashion. Both patients and caregivers were involved in movie evaluation, with pre-intervention surveys showing that before the movie, not all patients understood the fall prevention instructions correctly (for one type of instruction, only 33% of the surveyed patients had a correct understanding). After the intervention, understanding improved, and the number of falls decreased significantly in older patients. The findings suggest that novel methods of education can improve the participants’ understanding of nurse instructions, and it also suggests involving caregivers in the process of fall prevention.

Wilkinson et al. (2018) presented a literature review on the strategies of fall prevention outside of hospitals exhibited by older adults and their caregivers. The 17 studies, only 2 of which explored exclusively caregiver perspectives (four additional ones explored those of caregivers and patients), included a sample of only about 600 people, 102 of them caregivers. The findings suggested that the caregivers were mostly using the strategy of discouraging independence, which highlights that they might be ill-equipped to provide care and require additional education on the matter.

Zhao et al. collected information about acute care hospitals, which limits the article’s applicability to this project, but it should be highlighted that the article is a very thorough and well-documented investigation of implications of factors associated with falls (including injurious falls) for the prevention of falls. A major issue of the paper is that it is a literature review and not a primary source, but literature reviews are also useful in the development of arguments (Polit & Beck, 2017). Regarding the present project, the article justifies it by discussing educational interventions as an existing method of both preventing falls and engaging patients and their caregivers in fall prevention. It is noteworthy that the authors conclude that there is a need for more than single-component interventions, but they recognize the usability of educational programs as well.

Vonnes and Wolf (2017) focused on falls in oncology, which limits the applicability of the findings. Still, the project tested a specific fall prevention technique (Fall Prevention Agreement), which involved formal caregivers and older adults. The falls demonstrated a reduction over the course of two- and eight-quarters, the former demonstrating a sharper decrease of 37%, and the latter still showing a substantial decrease of 58.6%. The authors’ explanation concerned itself with the ability of the Fall Prevention Agreement to improve adherence and participation both for the team and patients. Additionally, the article comments on the ability of Fall Prevention Agreements to involve informal caregivers and families. Thus, the article exists mostly to highlight the importance of actual participation in fall prevention activities of informal and formal caregivers and patients, demonstrating that when a measure meant to enhance it is implemented, a reduction in falls is observed. From this perspective, the article can be used to confirm the importance of the contribution of different groups to fall prevention, including informal caregivers.

Ximenes et al. (2019) presented a study that began with the construction and ended with assessment of a booklet developed by nurses and patients and aimed at the prevention of falls in medical institutions. As a result, the topic is not fully consistent with the one selected for the project, but it can still be useful from the perspective of educational materials being useful in fall prevention. The booklet was validated and demonstrated Content Validity Index of 0.98-1. Patients deemed it understandable. The main weakness of the paper is the lack of actual testing of the booklet, but the authors justify the need for educational materials in fall prevention and additionally, they highlight the ability of patients to contribute information relevant for educational material design. Thus, the article supports the importance of educational materials and offers some information about the empowerment of patients and their families through their involvement in fall prevention.

Ang et al. (2019) carried out a qualitative study to gather information about the concerns exhibited by caregivers regarding the risk of falls in their patients. The size sample was small (22), and the authors only used one tertiary hospital from Australia. The goal was to interview (semi-structured) the participants and determine the themes emerging from the collected data. The authors found that there were issues related to caregiver awareness of fall risks, as well as their knowledge and ability to support their patients. Furthermore, a separate theme was connected to the support provided by healthcare professionals. The authors concluded that caregiver knowledge and awareness are critical in fall prevention, as well as their own well-being, as far as the concern about the patient falling is determined. Their recommendation is for healthcare professionals to offer caregivers sufficient information about falls to improve fall prevention and their well-being.

Black et al. (2018) offers a model of fall prevention that focuses on several elements, including patient mobility, injuries and fall prevention, as well as ensuring caregiver safety, especially from the perspective of musculoskeletal injuries. It should be highlighted that the article focuses on critically ill patients and ensuring their mobility, but still, the article is relevant to older people and fall risks since those are taken into account. Additionally, the caregivers in question are predominantly formal caregivers, but informal ones are also considered. Finally, the authors’ methodology consists of a literature review; the article is not a primary source. All of these features should be taken into account, but it can be suggested that the article demonstrates the importance of viewing the safety and other features of the well-being of caregivers while preparing fall prevention strategies. The numerous issues with the relevancy of this article can be used to also highlight the lack of the literature on the topic. Caregivers are not studied as extensively as patients when it comes to fall prevention.

Juckett and Poling (2020) focused on home- and community-based services; specifically, on their ability to perform fall risk screens and referrals to relevant services. The article used a qualitative approach, involving 26 staff members and administrators with the help of interviews, including focus group interviews. The results suggested that the staff of such services was able to perform fall-related services but was not trained to do it and had even less knowledge on actual fall prevention. Additionally, the service administrators reported a lack of connection with fall prevention providers. The authors recommended rectifying the named issues. It should be highlighted that this article discusses a form of professional caregivers, but it highlights the different types of services that such caregivers can offer. Additionally, it shows that even professional caregivers can require help in the form of fall prevention education. Therefore, the article is useful for the project by demonstrating the importance of fall prevention education.

Meyer et al. (2019) focused on people with dementia and the difficulty of engaging them into fall prevention strategies, highlighting the importance of caregiver involvement in such instances. The authors developed a discussion tool meant to engage both patients and caregivers in fall prevention. Aside from carrying out a literature review to support the tool, the authors also trialed it for six months with 25 patients, who had increased fall risks, and their caregivers. The findings allowed to conclude that the tool facilitated communication and engaged participants (both patients and caregivers) in fall prevention. It should be highlighted that this research was aimed specifically at people with dementia, which provides additional motivation for including caregivers in fall prevention. However, it is noteworthy that the goal of the authors was to engage the patients as well. The project is, therefore, capable of highlighting the importance of empowering both patients and caregivers through communication of fall prevention information.

Montgomery et al. (2020) focused on a program meant to training non-clinical caregivers to prevent falls outside of clinics, which is why this article is especially relevant for the project. The authors justified the approach based on the importance of falls for older adults, as well as the lack of routine incorporation of fall prevention into nursing practice. The solution that the authors proposed was the involvement of non-clinical caregivers with the help of the STEADI tool, which makes the article further relevant for the project; the use of pre- and post-test design is additionally able to direct the project’s design. Statistically significant increases in knowledge and confidence were identified, and the participants showed good retention of the information during the follow-up. However, the sample was small (less than 30 people), and it was only from the US, which is relevant for the present project but might not be very generalizable. The findings are still important, and crucially, they highlight the importance of caregivers in fall prevention, as well as the gaps in knowledge they had exhibited before the project.

In summary, there are a few sources on caregiver involvement in fall prevention, including prevention that is meant to be carried out with the help of education, that are published in the past few years and are in English. This seems to be a major drawback of the current literature on the topic, especially since the presented sources, as well as the previously discussed qualitative sources, suggest that these actors in fall prevention are important. Thus, it is critical to produce more literature on the topic, which justifies the present project. Additionally, the need for education and the potential positive outcomes of educating caregivers does receive some support in the recent literature. Therefore, the project can be considered justified.

Data Source

To justify the project’s data source, three recent articles will be reviewed to demonstrate the appropriateness of using EHR for research purposes. Thus, Penning et al. (2020) highlight that EHRs data is helpful in multiple types of studies, especially retrospective ones, but they also suggest that prospective studies should also employ the data source, in particularly, through quick access to EHRs that allows near real-time data utilization. Khairat et al. (2018) highlighted the importance of EHRs being accessible to researchers, possibly internationally, with the aim of disseminating data for research and related findings. With the help of a survey, the authors demonstrated that EHR accessibility remains an issue, which has implications for research. Bruland et al. (2018) focused on technical solutions in pseudonymization of EHR data and demonstrated that the integration of relevant services would facilitate research activities by reducing the time required to extract the data by more than 50%. Overall, it is well-acknowledged that research and EHRs can coexist, and that the latter are a very good source of research data.

Summary

Research suggests that the specific topic of the project is not very well-researched. Indeed, fall prevention education is a common topic in research, but specifically STEADI education is less often investigated. Fall prevention education for caregivers is rather rare. The topic can be considered a form of a research gap, which is exacerbated by the fact that most studies present individual interventions that need to be studied more than once and preferably with a large sample. Since sample limitations were the most common limitations for the literature described so far, it is a major issue. However, other limitations were also noteworthy, such as the specifics of the methodology (for example, the lack of randomization), the drawbacks of the methodology (for example, statistically significant differences between the two groups being compared pre-test), and other issues. Overall, the research is based on the literature that suffers from limitations and is occasionally not very recent specifically because there is not enough literature.

However, the findings still produce themes within this literature that can be helpful for the project. Thus, it is apparent that falls are a dangerous issue; that much is established in every piece of literature, but it is especially clear from the statistical sources included precisely for this reason. Consequently, it is apparent that falls need to be addressed, and one of the methods of doing so is fall prevention education, which follows from some of the causes and risk factors of falls. Education has been studied in a variety of circumstances, showing that it can achieve positive outcomes, including a reduction in falls, near-falls and fear of falls, among a few other things. STEADI as an intervention that is focused on education is generally supported by the literature, although more research would be helpful that would not focus on its implementation above all else.

It is also noteworthy that the current project will be using some of the parameters that have been established as potential outcomes of educational interventions for falls. Orem’s (1985) theory and the IOWA model are going to be used in concert, with the former explaining the key terms and variables, and the latter assisting in the process of STEADI implementation, which, as is shown in the literature, is not an easy endeavor. Research clearly demonstrates that the topic can be investigated in a variety of ways, including qualitative and quantitative ones. Controlled trials and randomized controlled trials were among the options that could be considered. They were employed to figure out the effectiveness of an intervention, which makes the suggestion appropriate for the present project. The details of the methodology will be discussed in the next chapter.

Methodology

This section is going to present the considerations related to the methodology of a quasi-experimental project dedicated to the application of CDC’s STEADI program to caregivers for the purposes of education. The purpose this quantitative quasi-experimental project is to determine if or to what degree the implementation of the CDC STEADI program would impact falls reported by the caregiver when compared to current practice among people aged 65 and older who run high risks of falling and are cared for by a caregiver while visiting an outpatient clinic in Florida over 4 weeks. The clinical question is concerned with the falls (percentages) in people aged 65 or older who are cared for by a caregiver who agrees to participate in the project. The project will compare the pre- and post-intervention rates to answer the question of which of them has more or less falls per 100 people (Newcastle upon Tyne Hospitals, n.d.; Washington Health Care Association, n.d.). The chapter will include a discussion of the statement of the problem and clinical questions, as well as project methodology and design and more specific details like population and instrumentation. Reliability and validity of the project, as well as its ethical concerns will be discussed as well, and a summary will be offered at the end of the chapter.

Statement of the Problem

It was not known if or to what degree the implementation of the CDC’s STEADI program (educational materials available to providers meant for older patient caregivers) would impact falls when compared to standard fall prevention interventions among patients aged 65 and older in an outpatient clinic. Thus, the project attempts to identify whether the STEADI program can reduce the prevalence of patient falls when applied to caregivers by healthcare providers. If yes, the project will assess the effectiveness of this intervention compared to the consequences of implementing usual standards of care, which, within the project site include non-uniform education applied to caregivers or patients, who are identified to be in need of information, without scheduled follow-ups. Caregivers are particularly unlikely to receive education, which is empowering for patients, but based on the information determined by the literature review, may be putting the caregivers at a disadvantage (Schoberer et al., 2016; Xu et al., 2019). The quality improvement project will implement an evidence-based intervention (STEADI), offering the providers additional tools for educating caregivers, and it will bring attention to the educational needs of caregivers, which are the primary positive outcomes of the project for its site.

Clinical Question

The project focuses on the implementation of the STEADI program, which can be considered the independent variable. The anticipated potential outcome is related to falls, which is the dependent variable. It is intended to quantify falls in terms of fall rates among the patients of the caregivers who will be involved in the project. As a quantitative project, the quality improvement effort will be finding a relationship between the two variables with the help of the following question:

Q1: To what degree does the implementation of the CDC’s STEADI program impact the rates of falls among patients aged 65 and older when compared to standard care in an outpatient clinic in Florida over four weeks?

This project includes the independent nominal variable (the STEADI intervention) and the dependent ratio variables (falls), as well as demographics information (gender and age), which will be presented in an ordinal manner. The data will be collected twice: first, some baseline data will be secured, and then, during the four weeks of the intervention, the information about falls will be collected for the single group of 45 patients (based on the GPower analysis). The project will use the methods that the site currently uses to collect data about falls, which is a typically oral questions the information from which is entered into patient records. In the end, the source of the data will be patient records (electronic health records, EHRs).

The presented details are suitable for the project because of the specifics of quality improvement projects, as well as the project question. Due to the fact that the project will not be able to carry out an experiment, a pre- and post-test quantitative project is proposed because it is the most feasible option that can deliver findings about relationships between variables (Polit & Beck, 2017). An experiment would be too time-consuming, as well as any other between-group approach (Creswell & Creswell, 2018; Polit & Beck, 2017), which is why a within-group method was required for responding to the clinical question. Additionally, the literature on the topic shows that a pre- and post-test project is very feasible and capable of producing the findings of interest (Montgomery et al., 2020; Ott, 2018). The selected design will be further justified below.

Project Methodology

The project focuses on quantifiable factors, including falls. All the outcome variables are quantifiable (Creswell & Creswell, 2018; Polit & Beck, 2017). Furthermore, the project intends to figure out the effectiveness of an intervention, which will be reflected in the way the use of CDC’s STEADI educational materials is going to appear to affect the falls as seen from the statistically assessed difference between the pre- and post-test data (Polit & Beck, 2017). Overall, it is apparent that in order to respond to the project’s questions, a quantitative methodology that focuses on quantifiable phenomena and quantitative data is required.

Indeed, quantitative approaches to data analysis will be required to determine the differences between pre- and post-test data, as well as the relationships between variables (Creswell & Creswell, 2018; Polit & Beck, 2017). On the other hand, there is no need for qualitative design (a design that works with qualitative data) because no uncountable and subjective topic are of interest; rather, the hard data is required. This need is reflected in the questions, which explains the choice. While the independent variable is nominal, its implementation is still quantifiable, and no unquantifiable phenomena are going to be considered. The questions do not introduce any sort of subjective or unquantifiable (qualitative) topic to be explored. Therefore, the qualitative approach to research does not appear to fit the requirements of the project (Creswell & Creswell, 2018; Polit & Beck, 2017). As mixed methods projects presuppose utilizing a combination of qualitative and quantitative methods, they are not necessary either; only quantitative project designs are considered.

Project Design

The quasi-experimental (pre- and post-test with one group) approach that the project has selected is justified for a number of reasons. First of all, the clinical question justifies it; the latter requires investigating a relationship between the variables, specifically the outcomes of an application of a program, and a quasi-experiment can help to achieve that outcome (Polit & Beck, 2017; Rockers et al., 2017). Furthermore, the limitations of the project, especially those related to time and access to potential participants are important (Polit & Beck, 2017; Rutberg & Bouikidis, 2018). The project cannot involve too many people for a long period of time, which is why the possibility of randomization was not very significant. However, it can be suggested that the project employs the most high-quality design possible within its constraints because a non-randomized trial is the next option regarding the level of an individual project (Creswell & Creswell, 2018; Polit & Beck, 2017). It is critical that the idea of a quantitative project is in line with that of a quasi-experiment, so the two choices are well-aligned (Polit & Beck, 2017). The literature dedicated to similar projects also justifies the solution (Montgomery et al., 2020; Ott, 2018). Overall, it is reasonable to state that the selected design is both capable of responding to clinical question and can be considered feasible within the constraints of the project.

Another very helpful design would consist of an actual RCT, which would allow the highest level of evidence to be produced (Polit & Beck, 2017). It would have been able to respond to the questions of the study. However, it would also have been very difficult to carry out, especially in terms of control (Creswell & Creswell, 2018; Polit & Beck, 2017). A well-matched and random sample that would probably be rather large would be required, and the settings of the project do not allow for such a sample. Additionally, the time constraints do not allow the project to use an RCT. Thus, the project uses the closest alternative to an experiment that it can feasibly carry out to collect the quantitative data that can be used to respond to the clinical questions.

The instruments and variables of the project can be described as follows. The project’s intervention is the STEADI program as applied to the staff of the clinic in question. The staff will be expected to apply the STEADI program to the caregivers of the patients who will be attending the clinic. The STEADI can be considered the independent variable, and its introduction is nominal (Polit & Beck, 2017). The dependent variables include fall rates (ratio), and the extraneous variables are gender and age of caregivers and patients (ordinal), all of which will be gathered from the EHRs of the clinic. The pre- and post-test design will be able to demonstrate the changes (if any) in the fall rates that follow the introduction of the STEADI toolkit for the staff, which makes it suitable for the described project.

Population and Sample Selection

The setting is an outpatient clinic in Florida, which does not employ STEADI at this point in time. The total population is the caregivers of people aged over 65; the project population are the caregivers of the patients attending that particular clinic, and the project sample is the 45 people who will be involved in the project based on a GPower analysis with 95% confidence interval. All the caregivers who correspond to EHRs data entries with all the required information (that is, out-of-clinic fall information before and after the STEADI introduction along with gender and age of the caregivers and their patients) will become the sample of the project; if any information is missing, the person will not be included in the sample. The primary inclusion characteristics are the person caring for a person older than 65 and the person they care for being a patient of the outpatient clinic; the patients themselves will not be involved in the education. Additionally, the lack of mental impairments and the ability to speak English will be important. All the data collected will be protected throughout its collection and storing, with the information only available to the project’s investigator (see below for ethical considerations).

From the perspective of direct involvement, the project will employ the staff of the clinic in question. The staff will be provided with the STEADI toolkit and the instructions related to working with the selected caregivers. Specifically, the staff will be expected to provide STEADI education to the caregivers in an effort to prevent falls. The data about the caregivers and their patients will be coming from the clinic’s EHRs. The staff will be required to collect the data about the patient falls from the patients or their caregivers before and after STEADI intervention to determine the potential effects of the use of STEADI education in the clinic.

Thus, the direct participants of the project will be the staff who will be educated on providing the education to the caregivers of the patients. They will be contacted directly through the site’s management and invited to participate in the project, with all the participants who are interested involved. The sampling is purposive, that is, a non-probability sampling that guarantees the involvement of the people who are of interest to the project based on their site of work (Polit & Beck, 2017). Polit and Beck (2017) highlight that there are limitations to this type of sampling; specifically, it is a non-random sampling, which affects the project’s generalizability. This limitation is going to be considered when reviewing the findings, but it can be viewed as a justified issue due to the fact that the project will only involve one setting.

No informed consent is required by the site of GCU, which is why the participants will be provided with the STEADI materials immediately after recruitment and instructed to use them with the caregivers of patients who fit the inclusion criteria. Throughout the four weeks, the providers will be collecting information about the falls in the 45 patients whose caregivers will be educated on fall prevention through caregiver reporting. Additionally, patient records will be used to figure out the fall rates in those patients four weeks prior to the caregiver’s education. The same source will be used for demographic data, which is why it is important to consider the topic of EHRs and their use in the project.

Data Source

The source of the data will consist of the medical records of the patients whose caregivers will have been educated on fall prevention by the staff members equipped by STEADI. The staff uses oral questions to collect the information about falls, which are recorded in the patient records. Thus, the dependent variables (falls) will be extracted from an already existing source of information. The same can be said about the gender and age of the caregivers and patients.

It should be highlighted that self-reported data would not be very reliable (Polit & Beck, 2017). The reasons for that do not have to be malicious (lying); the reporting population can simply forget about events that are relevant for the project. The fact that the caregivers may not have been paying close attention to falls prior to the project may also be a factor to consider. Overall, the data source is a limitation, but since the project seeks to limit the invasion into the caregivers’ and patients’ lives, it is difficult to propose an alternative, especially one that would not require their consent.

It should be highlighted that, as such, EHRs can be considered a critical source of data for research, studies and various projects. The literature on the topic indicates that researchers should be encouraged to use EHRs as a source of data, including the instances when it is done in nearly real time (Bruland et al., 2018; Khairat et al., 2018; Penning et al., 2020). Therefore, while EHRs are typically employed in retrospective studies, using EHRs in this project is also appropriate.

Validity

According to Polit and Beck (2017), the validity of a project can be improved by controlling external variables and the validity of the quantitative instrument of the project. In this project, the intervention is recognized as valid by the previously studied literature (Casey et al., 2017; Eckstrom et al., 2017; Johnston & Reome-Nedlik, 2020; Lee, 2017; Lohman et al., 2017; Mark, 2019; Mark & Loomis, 2017; Nithman & Vincenzo, 2019; Sarmiento & Lee, 2017; Vincenzo & Patton, 2019; Urban et al., 2020). Lohman et al. (2017) in particular discussed the validity of the tool, focusing on its risk assessment tools, finding, based on a large sample (almost 7400) that STEADI tools were valid (as in, capable of performing their functions) with the validity of 95.

From the perspective of the primary data source (EHRs), it should be highlighted that EHRs are a valid source of data (Bruland et al., 2018; Khairat et al., 2018; Polit & Beck, 2017), but specifically for this project, the falls outside of the clinic are self-reported and determined through oral questions by the staff. In other words, there is little opportunity to determine the validity of the questionnaire dedicated to falls outside of clinic. However, from the perspective of face validity, asking the patients or caregivers about such falls appears to be appropriate (Polit & Beck, 2017).

Reliability

The STEADI program has been shown to reliably produce positive outcomes in different conditions (Casey et al., 2017; Eckstrom et al., 2017; Johnston & Reome-Nedlik, 2020; Lee, 2017; Lohman et al., 2017; Mark, 2019; Mark & Loomis, 2017; Nithman & Vincenzo, 2019; Sarmiento & Lee, 2017; Vincenzo & Patton, 2019; Urban et al., 2020). Admittedly, more research is required on the topic. However, according to Lohman et al. (2017), the tool is valid and reliable.

From the perspective of the primary data source, the questions regarding falls outside of the clinic are unlikely to have been tested for reliability. However, it is reasonable to assume that the patients and caregivers who report the data provide reliable information about the falls the patients had experienced. Overall, the self-reported nature of the data is a limitation (Polit & Beck, 2017), which will be discussed when introducing the findings.

Data Collection Procedures

In order to collect the data, the following steps will be taken. First, the staff of the project will be approached (recruited) and provided with the tools that are included in the STEADI program, which include the education materials for caregivers and patients. Then, the staff will be educating caregivers on STEADI fall prevention with a focus on the caregivers caring for older people. The data about the caregivers, including their demographics, the demographics of their patients, as well as that about the out-of-clinic falls before the project’s initiation will be collected from the patient records by the staff.

All caregivers of the patients who meet inclusion criteria will receive the evidence-based intervention education for four weeks (once every two weeks), with only the people who attend all education sessions being included. The data about falls during these four weeks will be collected using the regular clinic method and entered into EHRs. After the end of the project (four weeks), the staff will once again collect the data about the falls. The data will be stored securely at the project site in the electronic form, and the copies made specifically for the project, if any, will be deleted in three years (see the information about ethics below).

Data Analysis Procedures

The project will be using one group, and the following variables will be of importance. First, demographics will be collected with the help of EHRs. Second, the fall rates will be collected with the help of EHRs for the period before and after the intervention. Thus, two main groups of data will be collected, and they will be analyzed differently.

The demographics will use descriptive statistics. What that means is that statistical analysis (most likely, percentages) will be used to describe the data (Polit & Beck, 2017). On the other hand, the fall rates will be using inferential statistics to infer any sort of relationships between them (Polit & Beck, 2017). To be more precise, it will be determined if there are any differences between the pre- and post-test fall rates within the group.

Based on GPower analysis, the project will be using a paired t-test for the inferential statistics, which is in line with the design of the project, as well as the specifics of the collected data (Polit & Beck, 2017). It will be required to determine if there is a statistically significant difference between the pre- and post-STEADI fall rates. Indeed, the project uses one group with pre- and post-test measurements, which is when paired t-test is needed (Polit & Beck, 2017). The GPower analysis has already helped to identify the required number of patients for the project (45); in case the number is too small, a non-parametric alternative might be required (Polit & Beck, 2017).

Potential Bias and Mitigation

There are multiple sources of internal validity threats in the presented project (Fox & Lash, 2020; Polit & Beck, 2017; Roush, 2020). The first one is the sample, which will be small and representative of only one location; as a result, it might not be suficiently generalisable despite the GPower analysis (Polit & Beck, 2017). Self-selection bias is relatively unlikely to matter, but given that the participants are likely to agree to participate if they experience the issue of falls, it is not impossible. Secondly, there is the issue of implementing the intervention; it is not impossible that the participants are not going to effectively implement the knowledge that they receive and that the caregivers will not follow it appropriately.

The mentioned issues cannot be really avoided. The sample cannot be increased, the participants’ use of STEADI cannot be tracked without significantly affecting their lives, and self-selection is inevitable for ethical reasons. An additional mitigation is concerned with several teaching sessions meant to improve the likelihood of the participants using STEADI. Finally, in terms of data analysis, a test that is suitable for the project will be selected, and its selection will be justified. Overall, however, most of the mentioned issues translate into significant limitations. In terms of limitations, the issues of sample, setting, timeframe and non-probability sampling methods are the most critical ones. All of them will mean that the project is not very generalizable. However, the project does not aim for generalizability; mostly, it intends to produce a positive effect within one setting.

Ethical Considerations

The following ethical considerations are of importance to the project. There are several aspects to ethics, according to Polit and Beck (2017) and the Belmont Report (Department of Health, Education, and Welfare, 1979), and they include the protection of the sample population well-being and data, as well as appropriate treatment of the sample population. In terms of well-being, the project does not involve significant concerns; it is assumed that the STEADI intervention might be capable of improving the caregivers’ ability to protect their patients but not affect any of the people involved negatively. Overall, the risks of participation are minimal to nonexistent, which is why no additional services for the participants’ mental or physical well-being are going to be offered.

In terms of the data, it is important to protect the participants’ confidentiality, which will be achieved through a series of actions. First, the raw data, which may be linked to the sample population, will not be available to anyone but the project investigator. Second, the data will be de-identified through the use of special identifiers (Polit and Beck, 2017). Third, the data will be destroyed within three years after the project’s completion. No conflict of interest is anticipated. No informed consent will be required since the project is a quality improvement project. The staff participants’ data will not be collected, and the risks to their well-being or confidentiality are nonexistent.

Limitations

The primary limitation of the project is the sample. The issue with it is that it is small and drawn from one single location. As a result, it cannot produce generalizable conclusions in response to the project questions (Polit & Beck, 2017). Furthermore, the fact that the findings will be reported by the caregivers is noteworthy. That means that personal errors and bias might affect the findings. It is not planned to supervise the work of the caregivers, which is why no specific means of protecting the project from this issue can be arranged. Overall, assumptions are associated with caregivers, including the belief that their reports will be honest and that they will be involved in implementing STEADI to the best of their ability. The same is assumed about the staff, which is important to recognize while reporting the findings. Additionally, the lack of a random sampling, the short timeframe and the limited settings are important. Overall, the project will not be generalizable, which is fine for a quality improvement effort that mostly aims for positive local outcomes.

Summary

The methodology consists of a quantitative quasi-experimental approach with a small sample of 45 that is going to be the primary limitation, even though it is supported by a GPower analysis. The project will ensure the well-being of the participants through appropriate ethics considerations, which will be relatively easy because of the lack of project-related risks, and the stated limitations cannot be avoided, which is why they are tolerated. The quality of the STEADI program is the project’s strength since it is valid and reliable. The direct participants are the staff, who will be educated on educating caregivers; the sample will consist of 45 patients, and their caregivers will be educated to prevent falls. The data source will be patient records, and the data analysis will consist of a paired t-test. The next chapter will present the findings and their analysis.

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