risk taking and falls amongst hospitalised older adults€¦ · risk taking and falls amongst...

Risk taking and falls amongst

hospitalised older adults

Assoc Prof Terry HainesDirector, Allied Health Research Unit, Southern HealthDirector of Research, Southern Physiotherapy Clinical

School, Monash UniversityDirector, Hospital Falls Prevention Solutions Pty Ltd

NHMRC Career Development Award 2010-2013

Co-investigators: Angel Lee, A/Prof Fiona McDermott,

Prof Bev OConnell, A/Prof Tammy Hoffmann

http://onlinelibrary.wiley.com/doi/10.1111/hex.12026/abstract

Falls during and after hospital

Reported rates of falls amongst older hospital inpatients tend to range between 3 and 20 per

1000 patient days. Haines T, et al. BMJ. 2004;328:676-9. Healey F, et al. Age Ageing. 2004;33:390-5.

During the 6 months following discharge, rates up to 7 per 1000 days have been reported.

Haines T et al. Clin Rehabil. 2009;23:973-85. Hill A et al. J Gerontol A Bio Sci Med Sci. 2011;66:1001-12.

Risk taking

Risk taking is the act of implementing a goal-directed option where

a) the behavior in question could result in more than one option, and

b) some of these outcomes are undesirable or even dangerous

Furby L et al. Developmental Review. 1992;12(1):1-44.

Background

Types of risk taking research i) those that explain the differences between

people who take risks and those that do not,

ii) those that explain the differences between situations that promote risk taking in most people

and situations that promote risk aversion, and

iii) those that explain both types of differences Byrnes JP, et al. Psychological bulletin. 1999;125(3):367

Method

Design Phenomenological study, constructivist approach

Participants / setting Hospital patients from inpatient medical and

rehabilitation wards (n=16), their informal

caregivers (n=8), and health professionals (n=33)

recruited from Southern Health hospital facilities

Method

Data collection approach Semi-structured face-to-face interviews and group

interviews

Probing perceived motivations for and factors contributing to risk taking that may lead to falls

Procedure Patients and care givers interviewed individually 2

weeks and 3 months post discharge

Health professionals interviewed in focus groups

Results

30 interviews across 16 patients 5 male, age 75.4 (6.9) years

14 interviews across 8 care givers 3 male, age 72.0 (10.1) years

33 staff at focus groups 12 nurses, 10 physios, 7 occupational therapists, 2

case managers, 1 social worker, 1 podiatrist

Types of risk taking

Enforced risk taking Instances where an older adult felt they have no

alternative but to attempt to perform the task

when you've got to go to the toilet, you've got to

go


Voluntary risk taking Instances where an individual felt they had a choice as

to whether they performed the activity or not

When I went in the toilet, I was usually in a hurry and that thing (the over-toilet seat) was out of position. I

used my crutches to drag it over the toilet, I could have easily fallen I could have asked for help, asked somebody to put back the toilet. (But I thought) No I won't bother and I did it myself quickly. I did. Luckily I

didn't fall, but I could have.


Informed voluntary risk taking Instances when the individual decided to take a

risk when he or she was aware of the risks

involved.


Mal-informed, voluntary risk taking Instances when the individual decided to take a

risk when not fully aware of the risks involved

Risk Taking

Voluntary

Mal

informedInformed

Enforced

EnvironmentOlder adult

Task

Risk Taking

Voluntary

Mal informedInformed

Enforced

Risk compensation

Testing physical

boundaries

Communication failure

Decreased or delayed

provision of assistance

Not asking for help

Risk compensation

Patients have cognitive issues and do not realize that they need assistance and are therefore getting up without the assistance or walking aid they need when they are walking

And the ward where I was, did have a lot of stuff in the corridor. The blood pressure monitor, machines and trolleys and all sorts of things, it was horrible if I wasn't paying attention I could have tripped over

Older adult

Task

Environment

Active consideration

Risk compensation

Awareness of self and

ability

Awareness of demand

of task

Difficulty of task

Different environment

Sensory loss

Cognitive decline

Health

Resistance to change

Denial

Ability to perform task

Assistance from others


Task

Risk Taking

Voluntary


Enforced

Risk compensation

Testing physical

boundaries




Not asking for help

Asking for help

I had been to the toilet three times and I wanted to go again and when she came, she went (profanity) and put her hand up and flopped it down to show not you again

He (another patient) was ringing his bell a lot, but that was just because he needed a lot of help. He couldn't see where things were, whereas I didn't ring my bell, not because I didn't need help, but because I knew if you ring too much they get cross with you they came and they would lean against the wall, (Staff would say) what is it now with a bad tempered attitude like you are a nuisance.

Older adult

Task

Environment

Act of receiving help causes

embarrassment

Cultural beliefsPerception staff

will not like patient

Feels embarrassed that

they need help

Perception staff are too busy to

help

Perception staff not allowed to

help

Belief they can perform the task

without help

Impaired capacity to ask for help

Older adult thinks staff look

unfriendly

Negative past experience

Not wanting to be a burden

Desire for independence

Trust of health professional

Asking for help


Task

Risk Taking

Voluntary


Enforced

Risk compensation

Testing physical

boundaries




Not asking for help

Decreased or delayed provision

of assistance

Today we are under staffed... You are running to try and give them their meds, let alone to

try and toilet them, you just don't have the

time in the day... We are being pushed to our

extreme that the nurse can't keep up

anymore

Older adult

Environment

Health service systems / resources

Location: Home or hospital

Task

Health professional time shortage

Location within ward environment

Competing tasks amongst

health professionals



Health professional /

family member / older adult interaction

Family member / caregiver

rostering of care provision

Physical structure of

ward environment

Health

Ability to perform

task

Discharge planning

processes


Task

Risk Taking

Voluntary


Enforced

Risk compensation

Testing physical

boundaries




Not asking for help


Nurse: Weve just got to keep on reiterating (what the mobility prescription is)

Physiotherapist 1: I think you know when patients arent doing exactly what you want them to do but its really, um letting them ummmPhysiotherapist 2: An acceptable riskPhysiotherapist 1: Yeah, an acceptable risk. And letting them get away with what you actually want them to get away with.Physiotherapist 2: I mean no one likes to be treated like a child and thats virtually what youre doing when youre bossing someone around

Older adult

Environment

Cognitive impairment

Difference in opinions between

health professionals

Communication systems


Amount of information

Older adult comprehends

incorrect information

Older adult unable to comprehend

correct informationTiming of

communication

Language of communication

Mixed / incorrect

information

Sensory impairment

Language barrier

Health professional

workload

Interpreter availability

Communication training

Health service systems / resources

Communication approach

Family member / care giver availability

Health professional

communication skills


Task

Risk Taking

Voluntary


Enforced

Risk compensation

Testing physical

boundaries




Not asking for help

Testing physical boundaries

The minute you become confident, you start to do things that you shouldn't be doing and that's how falls occur

They (family members) say Mum is okay, dad is okay, they dont need the shower chair, and they dont need the rail, whereas in actual fact they do. The patient says I dont normally use the frame, I can walk with nothing

Older adult

Environment

Task

Testing physical boundaries

Desire to test physical boundaries

Desire to be independent

Therapy & exercise

Discouragement / encouragement /

enablement to test physical boundaries

Desire to return to previous lifestyle

Desire to go home

Health professional objective to rehabilitate

Health professional objective to ensure

safety

Confidence to test physical boundaries

Supported

Unsupported

Family / care givers desire for older adult to be independent


Task

Risk Taking

Voluntary


Enforced

Risk compensation

Testing physical

boundaries




Not asking for help

Limitations

Limited to English speaking patients only Some insight provided by health professionals

Potential for recall bias Investigator previous clinical and research

experiences may have influenced results

Identified with staff perspective / issues more readily

Conclusions

Risk taking is not bad A part of rehabilitation

Need to promote supported risk taking and minimise malinformed risk taking due to

communication failure

Need to help patients with risk compensation, address negative experiences that may hinder

them from asking for help

risk taking and falls amongst hospitalised older adults€¦ · risk taking and falls amongst...

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