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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
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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.
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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
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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
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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
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Types of risk taking
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.
Types of risk taking
Informed voluntary risk taking Instances when the individual
decided to take a
risk when he or she was aware of the risks
involved.
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Types of risk taking
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
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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
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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
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
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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
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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
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
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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
Decreased or delayed
provision of assistance
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
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
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Communication failure
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
Communication failure
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
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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
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
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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
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
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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