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An Exploration into the Challenges to Engaging
Stakeholder in Falls Prevention
by
Nicola Jane Bell
A thesis submitted in partial fulfilment for the requirements for the degree of
Master of Science (by Research) at the University of Central Lancashire
March 2014
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University of Central Lancashire
STUDENT DECLARATION FORM
Concurrent registration for two or more academic awards Either *I declare that while registered as a candidate for the research degree, I have
not been a registered candidate or enrolled student for another award of the University or other academic or professional institution
or *I declare that while registered for the research degree, I was with the
University’s specific permission, a *registered candidate/*enrolled student for the following award:
_______________________________________________________________ Material submitted for another award Either *I declare that no material contained in the thesis has been used in any other
submission for an academic award and is solely my own work or *I declare that the following material contained in the thesis formed part of a
submission for the award of _______________________________________________________________ (state award and awarding body and list the material below):
* delete as appropriate Collaboration Where a candidate’s research programme is part of a collaborative project,
the thesis must indicate in addition clearly the candidate’s individual contribution and the extent of the collaboration. Please state below:
Signature of Candidate _______________________________________________ Type of Award ___ Master of Science (by Research) _________________ School ___ Health ______________________________________
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ABSTRACT
Background
Falls are a serious and prevalent concern for older people aged 65 years and over.
Preventative interventions are available across localities to inform about and address
falls risk factors. Following a community based whole-system intervention (‘Steady
on!’) successfully piloted in East Lancashire (phase one), this study (phase two) sought
to explore the challenges that face stakeholders to engage in falls prevention.
Method
An interpretive instrumental case study design was used to examine the perspectives
of stakeholders. Secondary analysis of phase one data, combined with key literature
themes from phase two, informed the schedule for semi-structured interviews (N=11)
with older people aged 65 years and over (n=6) and universal frontline staff (n=5). Data
analysis included reduction, display and verification of emergent themes. Ethical
governance was approved by UCLan Ethics Committee and NHS East Lancashire.
Findings
Recognition of age and capability; fear of the future and of falling; experience of falling
and the nature of support accessed and offered are key areas where the attitudes and
beliefs predominantly negatively affect engagement with falls prevention. Enablers to
engagement are typically converse to the barriers. These themes are primarily
subjective factors and personal to the individual, more so than the structure provided
by the system, though the latter maybe more influential than is overtly recognised.
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Conclusion
Falls and falls prevention are complex phenomena to understand. The heterogeneous
nature of falls corresponds with an inconsistent approach to defining what a fall is.
With little or no commonality, providing falls prevention interventions suitable and
agreeable for a majority of stakeholders to engage with is challenging. Appreciation of
the process and contributory factors to Successful Ageing may assist in encouraging
stakeholders to engage in falls prevention, to enjoy a healthy and active older age.
Key Words
Falls, Prevention, Ageing, Experience, Support
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CONTENTS
Student Declaration Form ................................................................................................. 3
Abstract ............................................................................................................................. 4
Contents ............................................................................................................................ 7
Lists of Tables and Figures .............................................................................................. 10
Acknowledgements ......................................................................................................... 11
Abbreviations .................................................................................................................. 12
CHAPTER 1: INTRODUCTION ........................................................................................... 13
1.1 Background ............................................................................................................ 13
1.2 Rationale ................................................................................................................ 14
1.3 The Aim of the Study ............................................................................................. 15
1.4 Ethical Matters ...................................................................................................... 16
1.5 Chapter Summary .................................................................................................. 16
CHAPTER 2: LITERATURE ................................................................................................. 17
2.1 A Background to Falls and Falls Prevention .......................................................... 17
2.2 Policy Context ........................................................................................................ 19
2.3 Search Strategy ...................................................................................................... 19
2.4 The Evidence Base ................................................................................................. 22
2.5 Synthesis of Literature Evidence ........................................................................... 33
2.6 Successful Ageing .................................................................................................. 39
2.7 Chapter Summary .................................................................................................. 43
CHAPTER 3: METHODOLOGY, RESEARCH DESIGN AND METHODS ................................ 44
3.1 Ontology, Epistemology and Philosophical Paradigm ........................................... 44
3.2 Theoretical Perspective ......................................................................................... 44
3.3 Methodology ......................................................................................................... 45
3.4 Ethical Practice and Governance ........................................................................... 48
3.5 Research Design .................................................................................................... 48
3.6 Data Collection Methods ....................................................................................... 52
3.7 Data Analysis ......................................................................................................... 53
3.8 Data Protection and Anonymity ............................................................................ 55
3.9 Chapter Summary .................................................................................................. 55
CHAPTER 4: FINDINGS ..................................................................................................... 56
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4.1 Phase Two, Part One Outcome ............................................................................. 56
4.2 Phase Two, Part Two: Introducing the Cases ........................................................ 57
4.3 Describing the Data ............................................................................................... 60
4.4 Key Themes ........................................................................................................... 69
4.5 Case Synopses ....................................................................................................... 89
4.6 Chapter Summary .................................................................................................. 90
CHAPTER 5: DISCUSSION ................................................................................................. 92
5.1 Research Reflections ............................................................................................. 92
5.2 Interpreting the Findings beside Falls Prevention Engagement ........................... 94
5.3 Mapping the findings to relevant literature evidence .......................................... 99
5.4 Discovering the subjectivity of definition ............................................................ 101
5.5 A Paradox of Theory and Findings: Prevention versus Pride? ............................ 102
5.6 What can I sign up for? Where do I find out more information? ....................... 111
5.7 Limitations ........................................................................................................... 112
5.8 Chapter Summary ................................................................................................ 114
CHAPTER 6: CONCLUSION AND RECOMMENDATIONS ................................................. 118
6.1 Responding to the Research Question ................................................................ 118
6.2 Recommendations ............................................................................................... 121
6.3 Suggestions for Future Research ......................................................................... 122
APPENDICES .................................................................................................................. 124
Appendix I: A Shortened Report on the Phase One Evaluation Study ...................... 124
Appendix 2: Lexicon ................................................................................................... 148
Appendix 3: NHS East Lancashire Programme Manager Approval to Proceed ........ 149
Appendix 4: NHS East Lancashire Research and Development Approval to Proceed
................................................................................................................................... 150
Appendix 5: Approval of Phase One Study by UCLan Ethics Committee .................. 151
Appendix 6: Registration Approval for MSc Study (Phase Two), Incorporating Ethics
Committee Approval ................................................................................................. 152
Appendix 7: Ethical Considerations Applied to the Study ......................................... 153
Appendix 8: Information Sheet Provided to Participants – Older People ................ 155
Appendix 9: Information Sheet Provided to Participants – Universal Frontline Staff
................................................................................................................................... 157
Appendix 10: Sample Consent Form for Participants ............................................... 159
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Appendix 11: Interview Preparation and Schedule................................................... 160
Appendix 12: Extract from Phase Two, Part One Notes – Recording the Themes and
Codes used to Annotate Secondary Review of Phase One Data ............................... 162
Appendix 13: Early Image of Data Reduction following Part Two Analysis .............. 163
Appendix 14: Refined Image of Data Visualisation following Part Two Analysis ...... 164
Appendix 15: Example Exploring the Interpretation of ‘Support’ Theme ................ 165
Appendix 16: Case Participant Descriptions ............................................................. 166
REFERENCES .................................................................................................................. 172
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LISTS OF TABLES AND FIGURES
Table 1. Literature Review Inclusion and Exclusion Criteria ........................................... 21
Table 2. Overview of Older Peoples’ Perspective Literature .......................................... 30
Table 3. Overview of Frontline Staff Perspective Literature ........................................... 32
Table 4. Interpretation of Successful Ageing alongside Falls Prevention ....................... 41
Table 5. Sample Criteria/Case Boundaries ...................................................................... 51
Table 6. Overview of Interview Sample .......................................................................... 58
Table 7. Case One: Participant Stakeholder Descriptions ............................................... 59
Table 8. Case Two: Participant Stakeholder Descriptions .............................................. 60
Table 9. Indication of the Beliefs and Attitudes to the Barriers and Enablers to
Acknowledge and Value Falls Prevention ..................................................................... 104
Figure 1. Conceptual Framework Based on Synthesis of Literature Review .................. 33
Figure 2. Visualisation of the Study Design ..................................................................... 46
Figure 3. Conceptual Framework Following Secondary Review of Phase One Data ...... 57
Figure 4. Key Themes Identified from Phase Two Data .................................................. 69
Figure 5. Illustration of Key Theme ‘Ageing’ and Sub-Themes ....................................... 69
Figure 6. Illustration of Key Theme 'Experience' and Sub-Themes ................................ 78
Figure 7. Illustration of Key Theme 'Support' and Sub-Themes ..................................... 84
Figure 8. Conceptual Framework Following Secondary Review of Phase One Data ...... 93
Figure 9. Synthesis of Conceptual Framework with the Primary Findings ................... 100
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ACKNOWLEDGEMENTS
I would like to begin by thanking the participants for sparing the time to be
interviewed for this research.
I am grateful to UCLan and East Lancashire Primary Care Trust for commissioning the
accident prevention Knowledge Transfer Partnership; and to Yvonne Skellern-Foster
and Diana Hebden at East Lancashire Hospitals Trust for their expert guidance in all
things ‘falls’.
I am indebted to the Royal Society for the Prevention of Accidents and British Nuclear
Fuels Limited for funding this research.
Thank you to my Academic Supervisors, Dr. Beverley French, Dr. Christina Lyons and in
particular Dr. Karen Whitaker, for their continued guidance, advice, support and
encouragement with this study. It has meandered so.
Finally I wish to thank my family and friends for their patience and support during this
research, and for helping me stay focused and enthused to enable the work to be
completed.
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ABBREVIATIONS
LA Local Authority
KTP Knowledge Transfer Partnership
PCT Primary Care Trust
UCLan University of Central Lancashire
WHO World Health Organisation
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CHAPTER 1: INTRODUCTION
This first chapter introduces the Masters empirical research study, ‘Exploring factors
that affect stakeholder engagement in falls prevention’. It provides an overview of the
study, including relevant background information, the rationale for exploring falls
prevention and stakeholder engagement factors, and the aim and objectives for this
study.
1.1 Background
It is estimated that one in three people over the age of 65 years will experience at least
one fall in a year, rising to one in two people aged 80 years and over (O'Loughlin,
Robitaille, Boivin & Suissa, 1993). Falls prevention is, therefore, a valuable and
necessary health promotion activity for health and social care providers to engage in.
It helps reduce the avoidable costs which are associated with a fall (physical,
psychological and financial), the consequential injuries and provision of care (World
Health Organisation (WHO), 2007).
Many Primary Care Trusts (PCTs)1 and Local Authorities (LAs) have delivered falls
prevention interventions to raise the awareness of falls to older people in an attempt
to minimise the incidence of falls and injuries sustained. As part of a Knowledge
Transfer Partnership2 (KTP) project, NHS East Lancashire PCT and the University of
Central Lancashire (UCLan) recently developed an innovative brief intervention as part
of a unique primary prevention ‘whole systems’ approach to falls risk awareness. This
involves the engagement of different people (including older people, commissioners
1 PCTs ceased to exist from April 2013. For information about their equivalent, please visit http://www.nhs.uk/NHSEngland/thenhs/about/Pages/authoritiesandtrusts.aspx 2 Knowledge Transfer Partnerships – for more information visit www.ktponline.org
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and providers from statutory and third sector organisations) to work together towards
a common goal and incentive. The falls prevention intervention, ‘STEADY on!’, tested
in three electoral wards in an East Lancashire borough over six months, reduced
admissions to local hospitals due to a fall in the home by 21% (n=10) over the pilot
period. These findings are specific to the context and delivery tailored to East
Lancashire, however ‘STEADY on!’, has been developed as part of a transferable model
which can be applied in alternative settings. A report on the process of the ‘STEADY
on!’ design, delivery and evaluation is available in Appendix 1.
1.1.1 Lexicon
A number of terms are used throughout this thesis. These are defined in relation to
this study context in Appendix 2.
1.2 Rationale
This Masters study will build on the work of the KTP project mentioned above (termed
the phase one study), where ‘STEADY on!’ was developed and piloted. This was a
community based programme designed to raise the awareness of falls risks by
concurrently delivering two streams of work; one with older people (aged 65 years and
over) within local social and residential groups and the other to universal staff who
work at the frontline and interface with older people within the area.
The findings of the phase one evaluation indicated the successful translation of the
accident prevention model from one context and client group to another.
Furthermore, the findings were positive in relation to attendee satisfaction and
educational benefit, however, additional themes were identified during data collection
and analysis. These related to challenges and barriers to engagement with falls
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prevention in general. At its inception, the phase one study was a distinct, standalone
project with no plans to develop further phases. However, with funding from the Royal
Society for the Prevention of Accidents, the opportunity to pursue a second phase
study (this Masters) into these additional pertinent research themes was enabled.
1.3 The Aim of the Study
The purpose of this Masters study was to examine more deeply the challenges and
barriers implied in phase one by stakeholders, primarily older people aged 65 years
and over, to acknowledging and participating in a falls prevention programme. To
explore this, the research question posed was: “What are the challenges to engaging
stakeholders in falls prevention?”
Running a singularly successful pilot programme, as described in phase one, is a
worthy achievement. However, if the success and impact of the programme are to be
maximised and sustained, exploring the characteristics of older people’s attitudes and
beliefs towards falls and falls prevention, aspects which may discourage these
stakeholders from engaging, can assist in positively shaping this and other falls
prevention interventions.
1.3.1 Objectives
To achieve the aim for this exploratory study, a number of key objectives were
identified:
i. Complete a systematic examination of relevant literature regarding adherence
to and motivation for falls prevention.
ii. Explore beliefs and opinions of the stakeholders about what a fall actually is.
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iii. Identify barriers and enablers for stakeholders to acknowledge and value falls
prevention.
iv. Explore the opinion of stakeholders on opportunities and challenges to
participate in community approaches to falls prevention.
1.4 Ethical Matters
Approval was granted for the phase one study, incorporating acknowledgement of
future data use in further study by the phase one host organisation (NHS East
Lancashire) and the UCLan Ethics Committee (see Appendices 3-5).
This Masters project has also received separate approval from the UCLan Ethics
Committee (see Appendix 6).
1.5 Chapter Summary
This chapter has introduced the research study, described the context and explained
the rationale for the inquiry. The study aim and objectives have been stated. The next
chapter will review the research literature and provide an analysis of the evidence in
relation to challenges to adherence to and motivation for falls prevention.
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CHAPTER 2: LITERATURE
The previous chapter presented the background to this study and explained the aim
and objectives. In this chapter, the research evidence concerning the perspectives of
older people and staff working with older people on falls prevention interventions is
reviewed. This will provide insight into the existing knowledge relevant to the research
question, “What are the challenges to engaging stakeholders in falls prevention?” In
particular, understanding is pursued around what is known about motivation to
prevent falls and facilitators to intervention concordance. As the primary target
population for this study is those aged 65 years and over, an appropriate model of
‘Ageing’ will be reviewed. The policy framework and current guidelines pertinent to
falls prevention interventions are also introduced within this chapter, setting the
context within which falls prevention is currently being delivered.
2.1 A Background to Falls and Falls Prevention
A fall is defined as “an unexpected event in which the participants come to rest on the
ground, floor, or lower level” (Lamb, Jørstad-Stein, Hauer & Becker, 2005, p. 1619).
Research into falls incidence suggests that over a third of people over the age of 65
years will experience at least one fall in a year (O'Loughlin et al., 1993). Leading
charities in the United Kingdom (UK) argue that falls are the cause of the vast majority
of fatal and non-fatal accidents involving people over the age of 65 years (Age UK,
2010; Royal Society for the Prevention Accidents (RoSPA), n.d). Internationally, the
World Health Organisation (WHO) (2010) has indicated that falls are the second
leading cause of accidental or unintentional injury and deaths.
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It is widely acknowledged that there are many risk factors contributing to the
likelihood of an older person falling (Easterbrook, Horton, Arber & Davidson, 2001;
Rubenstein, 2006; Tinetti & Kumar, 2010). These include intrinsic (of or about the
person) and extrinsic (environmental) factors. The heterogeneous and dynamic
relationship between the risks suggests that the consequence of a fall can be equally
as varied. Furthermore, falls are a risk factor for serious injuries such as a fractured
neck of femur or even death from associated co-morbidities. Irrespective of the injury
sustained, the impact of a fall on the individual can be physical and psychological, with
additional social and financial costs to consider. Where a fractured neck of femur is
sustained, Parrott (2000) puts the cost at £10,000 per person to the NHS, rising to
£25,000 per year with on costs. Given that the personal and economic costs are so
high, it is important to understand how falls can be prevented.
Reflecting on the multiple and complex falls risk factors, there are a range of falls
prevention interventions provided to avoid or help reduce falls risks (Gillespie et al.,
2007; Stevens & Sogolow, 2008) These include exercise classes (for example balance
and strength, chair based, and tai chi); home or environment modification; medication
review; vision assessment; education and training; and health promotion marketing
(for example co-ordinated multi-media advertising campaigns). Delivered as single or
multifaceted programmes, these are provided to individuals or community groups as
primary or secondary prevention interventions. The opportunity to access these
programmes can vary between communities and across regions depending on local
provision (Gillespie et al., 2007). Sustained uptake and adherence to falls prevention
programmes and interventions is reported to be low, averaging between 10 – 50% of
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attendance maintained (Robertson, Devlin, Gardner & Campbell, 2001; Day et al.,
2002).
2.2 Policy Context
The Department of Health (DH) has indicated a need for action on falls and falls
prevention for more than ten years. In 2001, Standard Six of the National Service
Framework for Older People highlighted falls as an avoidable threat to the health and
wellbeing of the older population (DH, 2001) and suggested key action points. The
National Institute for Health and Clinical Excellence (NICE) (2004) validated this with
clinical practice guidance, further substantiated by additional best practice guidance
for health and social care professionals on falls and falls prevention interventions (DH,
2009). It is noteworthy that the NICE guidance (2004) is clearly directed solely towards
healthcare professionals, whilst five years on (2009a), the DH guidance is clearly titled
to include both health and social care professions. However, despite calls for
integrated work and action on falls, there is no definite requirement for either health
or social care bodies to take responsibility for the action, or to implement any of the
recommendations (Oliver, 2009). Provision is at the discretion of local health and social
care providers, according to their current priorities and assessment of need. The
impact of this uncoordinated provision may itself be detrimental to the wellbeing of
older people.
2.3 Search Strategy
To examine the relevant evidence base, studies relating to factors of engagement with
falls prevention initiatives were sought.
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The electronic databases Medline, Cumulative Index to Nursing and Allied Health
Literature (CINAHL), BioMed, and Social Work Abstracts Plus were searched for
literature. The Medical Subject Headings (MESH) terms ‘accident prevention’,
‘accidental falls’ and ‘patient compliance’ were both ‘exploded’ and ‘focused’,
identifying a breadth of relevant literature. To narrow further, free text searches of the
terms ‘barrier$’, ‘engag$’ and ‘challen$’ were applied to the search strategy with the
Boolean operators ‘AND’ and ‘OR’. A search filter for best match of qualitative
‘specificity’ and ‘sensitivity’ focused the search further. This yielded 57 papers, of
which the abstracts were read as an initial means to filter the more suitable papers,
according to inclusion and exclusion criteria (see Table 1). Where the abstract
warranted further reading of the full paper, the paper was first scan read to gain a
greater insight, keeping the aim of this literature review and research question in
mind, and applying the inclusion criteria. Irrelevant papers were disregarded and the
remaining papers read in detail, with stricter focus on the quality of each study.
Whilst systematic principles were initially applied to the search strategy, this
progressed to include some purposive selection of literature to further refine the
selection of papers that would be examined intensively for the literature review.
Aveyard (2007) discusses that searching for papers by author is a valid approach to
capturing relevant literature. Rather than selection bias (Greenhalgh, 2010), it is
argued that this enabled a richer quality of papers be used in the review. Using this
final filtering mechanism, the number of papers identified for inclusion in the review
was reduced to six. This was based on a familiarity with the names of Academics with
specialist interest in falls prevention which the researcher acquired from both prior
work experience and reading of relevant literature.
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Inclusion Exclusion
Engagement, compliance and adherence
to a falls prevention intervention
Studies related to a particular co-
morbidity or particular population groups,
e.g. adults Parkinson’s disease or with
learning difficulties
Community based interventions Acute healthcare setting/ Inpatient falls
Primary and secondary prevention
interventions
Falls risk factors
Frontline staff who work with older
people
Experience of a fall
Older people (typically aged over 65
years)
Impact of a falls prevention intervention
on falls rate
Studies based in a developing world
Non English
Table 1. Literature Review Inclusion and Exclusion Criteria
The search strategy focused on papers discussing the risk factors to falling, not where
falls were a risk factor to an injury. For example, a common injury sustained by the
elderly following a fall is a fractured neck of femur, therefore the fall is the risk factor.
However this was not the required focus for this study. In addition, community based
studies took precedence over residential setting (nursing homes or long-term care
facilities). Papers discussing the effectiveness of interventions were plentiful but not
included here as this study is not concerned with the statistical measurement of
intervention impact. The assumed effectiveness of interventions may be relevant to
whether an individual chooses to sustain participation in an intervention, but the
statistical measure of effectiveness does not offer this same qualitative insight.
Although non-health databases were searched for relevant literature, suitable papers
discussing the practice of falls prevention with non-health personnel were not
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returned. As such, this summary of the literature includes only the perspectives from
practicing health professionals on falls prevention interventions.
2.4 The Evidence Base
The findings are presented in two sections according to the participants involved: older
people and health professionals. The literature was critiqued and guided by the suite
of resources available from the Critical Appraisal Skills Programme (CASP) (Public
Health Resource Unit, 2013). The use of a tool is recommended to provide systematic
structure to the review of research and help make sense of the evidence complexity
(Aveyard, 2007).
Six studies from western, developed countries were suitable and selected for review
(see Tables 2 -3). Older people formed the participant group for four studies, of which
the gender of these participants was predominantly female, aged over 65 years. The
remaining two studies sampled health professional participants for their views on falls
prevention interventions. The occupation roles included primary and secondary care
physicians, care co-ordinators and home health (community) nurses.
Data were mainly collected through semi-structured interviews and focus groups, the
exception to this being one verbally administered survey. Participant observation
during falls prevention interventions was not recorded as used. The principal
methodology for the studies was Grounded Theory (Glaser & Strauss, 1967) whereby
data analysis takes the form of constant comparison as themes emerge and are
validated. However, in one study (Whitehead, Wundke & Crotty, 2006) a form of
numerical analysis was applied to the qualitative data, providing a statistical
illumination of the findings.
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2.4.1 Studies of Older Peoples’ Views
Yardley, Donovan-Hall, Francis and Todd (2006) explored the perceptions of older
people (n=66) on advice available about falls prevention. This was with a view to
establishing a communications strategy for approaching falls prevention in a positive
and helpful manner, to avoid negative responses and help address the low uptake rate
of falls prevention interventions. The use of different media formats aided the
discussion around forms of suitable communication. An insight into personal acuities
of falls emerged through a sometimes ambiguous discussion of falls prevention
messages. For example, there appeared agreement that falls prevention advice is
required but denial that the message was relevant to them as older people.
Furthermore, a frequent comment was that falls prevention was ‘just common sense’
which contrasted with another view that there should be more falls prevention advice
available. Participants appeared unclear about what information they wanted and
uncertain that they would always apply the advice to themselves because it was “not
needed, not wanted and not helpful” (Yardley et al., 2006, p. 513).
The views of community based participants from a wide range of socio-economic
backgrounds, including those who had and had not previously experienced a fall were
gained. Yardley et al., (2006) noted that the invitation for older people to participate
had to be adapted to encourage ‘younger’ participants (those closer to lower age
range rather than the higher bracket) to take part in the study. Thus, the study
changed from initially covering the adapted invitation points, before addressing the
primary focus.
This insight offers perhaps a ‘finding’ in itself; ‘younger older people’ do not wish to
associate themselves with falling. Kohli (2007) submits that the distinction between
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‘younger old’ and ‘older old’ is linked to the proportion of the lifespan spent in
retirement (taken to be aged 65 years). In chronological terms, ‘younger old’ fits those
65-74 years, whilst ‘older-old’ 74-85 in age (Moody & Sasser, 2012). As humans live
longer, Phillips, Ajrouch and Hillcoat-Nalletamby (2010) suggest that further
differentiation is needed to distinguish health and activity status. The impact of this
segmentation of life stages in such a way, however stringent to the actual age, may
impact on the engagement of older people collectively in falls prevention, as appears
the case in the Yardley et al. (2006) study.
To facilitate the uptake of falls prevention interventions, Dickinson et al. (2011)
explored older peoples’ preferences and experiences of falls prevention interventions
to understand what older people felt they needed. An equal number of facilitators and
barriers were identified, of which two were directly contrasting themes:
‘knowledge’/‘lack of knowledge’ and ‘experiencing benefits’/‘perceived lack of
benefit’. The remaining facilitating factors supporting older people to take up falls
prevention interventions were accessibility, appropriate level/type of activity, high
quality facilitation and appropriate design of intervention. Elements which were found
to inhibit uptake were poor availability, health issues, lack of time and language. Both
the supporting and preventing factors included practical issues as well as those
regarding intervention perception. For example, the accessibility and availability of
interventions are practical aspects, whilst opinion about the benefits experienced is
personal to the individual. Overall, subjective issues appeared to be more prominent
than objective, practical factors.
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Dickinson et al. (2011) sampled participants purposively (n=187) through their
attendance at a range of falls prevention interventions. The sample included those
who had withdrawn from an intervention and were recruited with this in mind to gain
insight from an opposing viewpoint. Participants had mixed experience of falls, and a
third were of South Asian or Chinese descent. This ethnically diverse sample enables a
cultural insight into falls, essential for representation of Britain’s multi-cultural society.
Falls are not incidents that only affect the white population of Britain, but may affect
any older person from any background or heritage.
Simpson, Darwin and March (2003) invited older people who were ready for discharge
from hospital back into the community to discuss the precautions they were prepared
to take to prevent a fall. Three specific areas of importance arose. Regarding the first
area of ‘taking care’, actions that constituted ‘taking care’ and beliefs behind those
actions were presented. These included avoiding activities that may be perceived as
risky and taking more time to complete activities to reduce the falls risk. The remaining
two themes were intervention specific, relating to exercise and a home safety check
consecutively. ‘Willingness to exercise’ incorporated an awareness of balance exercise
to prevent falls (understanding what the exercise entailed and the importance of
exercise) and also the barriers to exercise (where exercise is thought to exacerbate
pain or injuries, or the exercise is inappropriate for older age). The third key area was
‘having a home safety check’. This included how older people attributed safety within
their home and to their behaviour, and their concerns over the interventions available
based on previous experience and general wariness.
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Although this study may be categorised as an acute based study, it has been included
here as it explicitly states that all participants (n=32) were imminently due to return to
live in the community. The sample were identified through a ‘Concern about Falling’
interview survey; those scoring as ‘concerned’ about falling were asked to participate.
This has the potential to influence the findings as the participants may have already
thought about falls prevention more than those who weren’t concerned about falling.
The random, impartial nature of falls does not differentiate between those who are
concerned about falling, and those who are not. Falls can happen to anyone however
concern may be a factor that makes participants more receptive to interventions.
The attitudes to falls and injury prevention of older people who had attended the
emergency department as a consequence of a fall were assessed by Whitehead et al.
(2006). These findings are presented as a count of frequency of the surveyed themes
(n=60 unless otherwise stated). Relating to exercise, the most frequently occurring
barrier was older people not having enough time to participate (28.3%). Study
participants also felt that they were active enough (25%), or that they ‘can’t do’ the
exercise (20%) and transport issues were a problem for 18.3%.
For findings concerning a medication intervention, a desire to have proof of the
benefits was indicated by 18.3% of the older people, and 10% were worried about the
potential side effects of preventative brittle bone medication. For those to whom this
specific question was relevant (n=17), when asked about reducing psychotropic
medications to reduce falls risk, an equal number indicated that they were concerned
about not sleeping (29.4%) or would only be willing if they were supervised/advised by
their GP (29.4%).
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The concluding element of this study involved thoughts on a home safety assessment
by a health professional. A third of the older people felt that their home was already
safe enough, whilst 28.3% of participants had already had at least one safety
assessment. The authors indicate that the majority of these latter participants would
not have another home safety assessment, though the exact response rate is not
quantified. This may suggest that older people do not place much value onto home
safety assessments.
Whitehead et al. (2006) identified participants through applying criteria to the sample
in a larger randomised control trial investigating the implementation of a falls
prevention programme within an emergency department (Whitehead, Wundke, Crotty
& Finucane, 2003), though the criteria are not outlined in the paper. From this frame,
participants were then purposively and conveniently recruited to this study if they
were older people who had attended the emergency department as a consequence of
a fall. The older people (n=60) all returned to live within the community following
treatment. This is an anomalous study as it themed participant responses and then
quantified the qualitative engagement factors. This enabled data analysis to be
converted from thematic to descriptive prevalence allowing the significance of each
theme to be statistically gauged. This does not distract from its value – the themes
identified bear relevance to this study, especially as it is presumed the participants
would have a vested interest in future engagement to prevent further falls.
2.4.2 Studies of Health Professionals’ Views
Fortinsky, et al. (2004) and Chou, Tinetti, King, Irwin and Fortinsky (2006) approached
their research on falls prevention from a different perspective. Both were concerned
28
with the viewpoints of health professionals on falls and the barriers to addressing falls
prevention in practice. Explicitly, Chou et al. (2006) wanted to identify the specific
obstacles and enabling factors to integrating falls prevention into primary health care.
The findings were categorised into three sections, relating to the physician, logistics
and systemic factors, and physician perceptions of older persons’ reasons, further split
into both barriers and facilitators to uptake. More barriers than facilitators were
identified. Obstacles comprised: a lack of general awareness of falls and falls
consequences, competing priorities to identify or address other illnesses, time and
transport requirements to attend interventions and a lack of reporting of falls.
Enablers included physicians linking falls prevention to other geriatric morbidities, for
example increasing dizziness and osteoporosis, and family members attending with
older people increasing the intervention uptake. This insight offers an alternative view
of the barriers to be addressed and the facilitators to be promoted if physicians are to
encourage engagement with falls prevention interventions.
From a sample frame of 212 primary health facilities (practice size ranged from one to
five physicians), Chou et al. recruited 18 participants; a small sample though it is stated
that thematic saturation was reached by this point. The lack of response, despite up to
six attempts to contact physicians to participate could again be reflected upon as a
relevant finding by the authors: the priority placed on falls prevention by healthcare
professionals against other workload and time pressures.
Addressing factors within clinical practice, Fortinsky et al. (2004) explored the extent to
which health professionals applied recent falls prevention education to patient
29
consultations with the purpose of gauging the barriers encountered. A total of 33
participants were interviewed.
Fortinsky et al. (2004) distinguished between the physician directly intervening in the
patient’s care and the physician referring the patient on to an external programme of
falls prevention. Obstacles from each outlook were discussed. The most frequent
reported barrier to successfully intervening with falls prevention was patient
compliance. There was some overlap noted in this (patient compliance was also noted
as an issue when physicians wanted to refer the older person) whilst other factors
were strategy specific. For example when referring a patient to a falls prevention
initiative, availability of an appropriate physician was noted as a barrier but this was
not highlighted if the consulting physician was actually intervening. When asked what
tactic would be taken if a target to reduce falls of patients was introduced, personnel
provided three responses. These were: a knowledge of falls incidence would prompt
action; understanding of local protocol to intervene or refer to prevention
programmes; and consideration of factors influencing patient compliance.
Table 2 provides an outline of the literature reviewed regarding older peoples’
perspectives. Table 3 summarises the literature from the view of frontline staff.
30
Author,
Date
Aim of Study Methodology,
Method
Main Findings/Themes Discussed Strengths, Limitations
Yardley et
al., 2006
To establish what
older people view as
good/bad
approaches to falls
prevention
communication
-Qualitative,
Grounded theory
-Focus groups, face to
face interviews
-Unaware/misunderstanding of
advice
-Advice perceived as good but
irrelevant to the participants (older
people), good/useful only to other
people who might need it
-Advice mostly ‘common sense’,
obvious
-Increased falls risk/falling seen as an
inevitable consequence of ageing
-Views taken from cross section
of community members
-Team review of data analysis to
agree codes
-Changed interview schedule to
attract more participants
-Potential bias: token of
appreciation of participation
given to service user
Dickinson et
al., 2011
To identify barriers
and facilitators to the
uptake of falls
prevention
interventions by
older people
-Qualitative,
Grounded theory
-Focus group or semi-
structured interview
- 12 key facilitating/barrier themes,
some the antithesis of the other inc.
knowledge/lack of knowledge;
accessibility-availability/lack of
accessible and available intervention,
benefits, design, activity, time and
language
-Large, mixed ethnicity sample
size
-Topic guide developed with
steering group
-Sessions took place directly
after a falls prevention
intervention
Simpson et
al., 2003
Examined
precautions older
people are prepared
to take to prevent
falls, including
utilising an
intervention
-Qualitative,
Grounded theory
-Semi-structured
interview, face to face
-Three main themes with sub-themes;
-Taking Care; actions and beliefs
-Willingness to exercise; awareness
and barriers
-Having a home safety check;
attribution of safety and concern
about intervention
-Small sample
-Interview schedule guided by
literature review
-Interviews not audio recorded
-No respondent validation
-Author discussion of
analysis/coding
Table 2. Overview of Older Peoples’ Perspective Literature
31
Author,
Date
Aim of Study Methodology,
Method
Main Findings/Themes Discussed Strengths, Limitations
Whitehead
et al., 2006
Assess the perceived
barriers and
understand the
factors that motivate
acceptance &
undertaking of falls
preventions
strategies by older
people
-Small part of larger
RCT
-Interviews – face to
face
- Responses coded,
counts and
percentages used to
summarise codes;
-Statistical analysis of
codes using SPSS
-Attitudes to falls and prevention
-Barriers including time, availability,
accessibility of interventions
-Acceptance of a falls prevention
strategy, incorporating
behaviour/lifestyle change
-Provision of information
-Descriptive statistical
illumination of qualitative data
-Small sample
-Chi-square & t tests
Table 2. Overview of Older Peoples’ Perspective Literature (continued)
32
Author,
Date
Aim of Study Methodology,
Method
Main Findings/Themes Discussed Strengths, Limitations
Chou et al.,
2006
Investigate barriers &
facilitators to
integrating falls
prevention into
primary care
-Qualitative,
Grounded theory
-Semi structured
telephone interviews
-3 key themes with sub-themes;
-Physician factors
-Logistic and systemic factors
-Physicians perceptions of patient
factors
-Recent falls outreach provided
-No relative importance given to
themes
-Low response rate; small sample
-Data analysis triangulated
Fortinsky et
al., 2004
Views of health care
providers on extent
physicians address
falls prevention and
the barriers
physicians perceive
from older people
-Structured interview
survey administered
via telephone or face
to face
-Cross sectional
-Intervention – Lack of patient
compliance (unwilling to make
sacrifices; unwilling to change;
stubbornness; vanity; bad habits)
-Referral - Physician availability
and co-operation; Service
availability
-Provider knowledge – of
incidence, protocols;
-Patient knowledge - to facilitate
compliance
-Four types of health professional
included:
1.Emergency department physicians
2. Hospital based discharge
planners/care co-ordinators
3. Home health agency nurses
4. Office-based primary care
physicians
-Small sample size
-Recent falls education given to
providers
-Participants reporting ideal
behaviour
Table 3. Overview of Frontline Staff Perspective Literature
33
2.5 Synthesis of Literature Evidence
The different methodologies, contexts and aims of the research literature make direct
comparison across the studies unachievable. However, four broad themes were
identified; ‘Knowledge’, ‘Communication’, ‘Beliefs and Attitudes’, and ‘Interventions’.
The themes emerged from the perspectives of both types of sample groups: older
people and healthcare staff, and characterise an intricate weave of person-centred and
system based issues, as discussed below. The nature of each theme may directly inhibit
engagement, promote engagement or vary, depending on its composition and other
influencing factors. The relationship of the four themes is illustrated in Figure 1.
A Venn diagram shows the interconnectedness of each theme. The figure also suggests
the complexity of the challenge to engaging stakeholders in falls prevention.
Knowledge and
Education
Communication
Attitudes and Beliefs
Intervention
Figure 1. Conceptual Framework Based on Synthesis of Literature Review
34
2.5.1 Knowledge and Education
What is known and understood about falls, their incidence and impact appears to be
lacking for staff (Fortinsky et al., 2004; Chou et al., 2006), whilst awareness of the
different prevention interventions available seems absent amongst both older people
and staff alike (Dickinson et al., 2011; Fortinsky et al., 2004; Yardley et al., 2006). This
poses as a distinct barrier to engaging both parties in falls prevention because they are
not aware of the negative consequences to be able to make an active decision about
whether to do anything about their personal situation or that of their patients.
Furthermore, if knowledge of falls prevention interventions is minimal, the
understandable result is that their uptake is low due to a lack of awareness about their
existence.
Whitehead et al. (2006, p. 541) propose that the provision of information as part of a
‘consciousness raising’ process may encourage uptake of exercise and home safety
assessment. If more falls prevention information were available, the issue would
change from being a lack of available knowledge to then becoming a choice of
concordance made by the older person. Put simply, the barrier would move from being
external provision to internal decision. It must be recognised though that there may
then be other system barriers, such as access, time and location, in addition to the
individual knowing about is potentially available, which impact on the engagement
with the interventions.
The use of specific training about falls and falls prevention is discussed by Fortinsky et
al. (2004) and Chou et al. (2006). Engagement in falls prevention may be encouraged
by educating staff on an official basis, especially if staff are to be formally recognised
35
for their learning efforts. However to adopt a similar approach for older people would
be inappropriate. Dickinson et al. (2011) suggest that a form of social marketing might
encourage more effective dissemination of falls information. As a profile raising and
information providing exercise, this would potentially enable a broad delivery to the
public whilst giving a targeted reach into older populations.
2.5.2 Communication
As with most aspects of communication, the tone of the information provided and how
it is pitched when delivered can have a great impact on how the message is received
and acted upon. The study by Yardley et al. (2006) focused predominantly on this
matter, involving participants from a range of socio-demographic backgrounds. The
interpersonal skill of the health practitioner in communicating with the older person
about falls, falls risks and interventions is significant in how well and to what extent
the prevention message is received. Inter-personal skills, tacit knowledge and
empathy to the circumstances, principles and situation of older people will affect their
response to the preventative information. Yardley et al. (2006) describe this as the
quality of facilitation.
An obvious challenge to understanding risks and uptake of interventions is the
language in which they are delivered. This was recognised by Dickinson et al. (2011) as
one third of the UK based study participants were from South Asian and Chinese
descent, and a total of six languages (including English) were spoken. One study
commented on the type and design of media, stimulating responses from participants
through sharing examples of materials (Yardley et al., 2006). The type and format of
the media, for example leaflets or video messages, received mixed response,
36
potentially affecting the engagement with the shared information. This could be true
for both the English and non-English speaking and literate populations.
2.5.3 Beliefs and Attitudes
A prevalent view from the older people was that components of falls prevention
information were useful, but they were not applicable to themselves (Simpson et al.,
2003; Yardley et al., 2006). This perspective is problematic, as a failure or aversion to
recognise ones ageing and therefore increased susceptibility to falling will hinder
acceptance of advice and engagement with a preventative programme. ‘Healthy
ageing’ is a contemporary phrase, identifying the delicate balance required to maintain
independence whilst providing a level of support to promote wellbeing as a person
gets older. An aligned term, ‘Successful Ageing, is explored further in section 2.6.
An additional view was that older people felt they were already taking care of
themselves and were ‘safe enough’ with the precautions they were making
(Whitehead et al., 2006, p. 541). This, coupled with the opinion that most falls
prevention is just ‘common sense’ (Yardley et al., 2006, p. 514), are distinct challenges
to overcome, if older people are to be encouraged to consider heeding advice and
undertaking a preventative intervention. The advantages of following preventative
strategies must be clear and apparent. Where the issue is ‘having time to participate’
(Dickinson et al., 2011, p. 179), this viewpoint should be offset with the benefits that
the intervention could bring. These may include short and longer term advantages
which may not automatically come to mind in relation to falls, for example the social
elements of exercise groups. If older people do not recognise and understand the
37
benefits, it will be harder to emphasise the importance to make or find the time to
participate.
Linking both of these considerations is the issue of reporting of falls. The standard
estimate of falls incidence may not be a true reflection of the number of falls those
aged over 65 years sustain. This is due to a number of reasons, not least the
embarrassment, shame and denial older people (and younger people too) feel when
admitting to a fall (Chou et al., 2006, p. 121). For older people, where both pride and
independence are at stake, overcoming the discomfort of admitting to and sharing
details of a fall are important considerations for health professionals.
2.5.4 Interventions
The availability of an intervention posed a barrier to uptake in some studies, and it was
noted that across localities, equity in provision was not present (Whitehead et al.,
2006; Chou et al., 2006; Fortinsky et al., 2004). If interventions are not provided then
older people cannot be referred to them; an obvious barrier to uptake and
engagement. Coupled with this, an issue of access to services was recognised
(Fortinsky et al., 2004). Access is described in terms of being allowed to attend a
session (i.e. being referred by a health professional where self-referral is not an option)
and also by the physical location of the intervention and whether the older person can
get to it. In addition, interventions located within health settings were associated with
treatment and perceived negatively. Yardley et al. (2006) concluded that older people
want the positives of falls prevention to be represented. Delivering interventions in
local community and leisure centres would credit this, and simultaneously address
issues of local access.
38
The studies by Dickinson et al. (2011), Simpson et al. (2003) and Fortinsky et al. (2004)
recognised that interventions have to be appropriate to the health of the older person.
Concern that the intervention would exacerbate another existing condition or that
simply the older person would not be able to participate due to poor health was
evident from both the perspective of the older people and health professionals.
Simpson et al. (2003) went on to point out that older people have to be willing to put
the effort in to participating in the intervention. This point is inextricably linked to the
‘Beliefs and Attitudes’ of older people; if the benefits of the interventions are not
either known or appreciated then it may be reasonable to expect that the older person
declines to put the effort in. As Dickinson et al. (2011) acknowledged, a distinct barrier
to uptake of any intervention is a lack of understanding of the range of benefits that
the intervention may provide. These include the probable positive impact on other
areas of health, such as social, physical and psychological wellbeing.
Health professionals may have a preference for referring older people whom they are
treating or caring for, to a particular form of falls prevention intervention. This may be
based on their previous experience or knowledge of the intervention having particular
outcomes. The choice of intervention should be made with the needs of the older
person in mind, and not to fit with the outlook of the professional. Fortinsky et al.
(2004, p. 1525) differentiated between the health professional directly ‘intervening’
with a falls prevention intervention, and the health professional ‘referring’ the older
person on to another agency or group for the intervention. The option of refer or
intervene may be due to what is available locally, and how accessible it is for the older
person, as discussed above. As with all areas of healthcare, one person cannot be a
specialist of all areas of practice. However, if a basic awareness of interventions and
39
their benefits was known, this may assist in bridging the gap between prompt
intervention and referring to an external or additional professional. Provision of locally
specific knowledge of the interventions may also help the older person knowing what
they are going to be doing and perhaps more importantly, why they are going to be
doing it. Accordingly, the link and connection between the themes ‘Knowledge and
Education’, ‘Attitudes and Beliefs’ and ‘Interventions’ starts to gain clarity.
‘Communication’, though not explicit, will similarly play an important part.
2.6 Successful Ageing
As this study is primarily considers people aged 65 years and over, the model of
Successful Ageing has been reviewed and included in this chapter to complement the
literature evidence. In addition, falls are presented in the literature from a health care
perspective, which predicates falls as an illness leading to an intervention. Successful
Ageing is therefore introduced as a guiding model for the philosophical approach to
the study; as wellness, not illness.
To age successfully involves a healthy journey through older age; a life that is actively
lived to the point where life ceases (Ouwehand, Ridder & Bensig, 2007). The notions of
‘ageing well’, ‘healthy ageing’ and ‘active ageing’ have grown increasingly as public and
preventative health considerations (DH 2004, 2006, 2008, 2009b, 2009c, 2010; WHO,
2002). Rowe and Kahn (1997) introduced the phrase ‘Successful Ageing’ in
gerontological respects, to refer to the maintenance of a person’s ability as their age
increases (Stroebe, 2011). At a broad level, successful ageing distinguishes itself from
pathological ageing, where illness or disease influences the life-course of the
individual. Where ageing is non-pathological (continues without disease), ‘successful’ is
40
further separated from ‘usual’ ageing by the low risk of pathological development
combined with high functionality of the individual that is upheld (Rowe & Kahn, 1997).
At a more detailed level, there are three components which must be attained and
maintained to afford the outcome ‘Successful Ageing’. These are: the absence and
avoidance of disease and risk factors for disease; maintenance of physical and
cognitive functioning; and active engagement with life (including maintenance of
autonomy and social support). This vies away from the assumed and stereotypical
consequences of getting older whereby there is an automatically anticipated decline in
physical fitness, cognitive acuity and general health and wellbeing. Rowe and Kahn
(1997, p. 434) further propose that ageing characteristics, such as fitness, acuity and
wellbeing, may be age related, but are not age dependant. With regards to falls and
falls prevention, this could translate that whilst some falls risks may increase with age,
they are not caused by ageing itself.
Rowe and Kahn (1997) anticipate that the characterisation of Successful Ageing will
help to further define criteria for ageing successfully, and subsequently contribute to
developing suitable initiatives to promote ageing with lower risk and higher function.
Falls prevention interventions, as mechanisms to reduce factors and risks to falling,
and any consequential effects, support the delivery of the ideal of Successful Ageing.
From this point of view, it could be assumed that engagement with falls prevention
would be instinctive. Components of the Successful Ageing model may be mapped to
the intention and interventions of falls prevention. This is summarised in Table 4. To
note, the translation to falls prevention is derived from a number of sources: prior
knowledge gained through working on previous falls prevention projects such as
41
‘STEADY on!’; theory and understanding gained from reviewing the literature;
application of the researchers’ logic and perception.
Rowe and Kahn’s (1997) Successful Ageing Component
Translation to Falls Prevention
Low probability of disease and disease related disability
- Staying healthy - making informed lifestyle choices - Engaging with activities to reduce risk of falls - Avoiding actions which increase the risk of falling
High cognitive and physical functioning capability - including self-efficacy
- Applying reasoning to understand and comprehend the potential benefits of falls prevention - Remaining orientated and reacting appropriately to extrinsic risk factors - Believing in one’s own ability and resources to reduce the likelihood of falling
Active engagement with life - interpersonal relationships including support - productive activities
- Recognising the reciprocal value of social interaction and activity on health and wellbeing - Utilising support channels for aid with activities of daily living as required, especially higher risk chores and transport to appointments - Accepting advice, encouragement and assistance regarding interventions - Appreciating increased productive activity is linked to lower age (years) as appears functioning to a higher physical level
Table 4. Interpretation of Successful Ageing alongside Falls Prevention
Deliberating on Successful Ageing, Bowling and Dieppe (2005) suggest the concept is
enigmatic and one which is not yet singularly defined. It is ambitious to imagine a life-
course comprising of no illness or disease to affect the progression through ageing, as
advocated by Rowe and Kahn. Bowling and Dieppe (2005) suggest that three
alternative perspectives on Successful Ageing exist. The biomedical, focusing on the
absence of disease; psychosocial, highlighting the life satisfaction, autonomy and
independence, coping and self-esteem; and lay-views incorporating accomplishments,
sense of purpose, productivity and contribution to life.
42
Once again, it is proposed that to age successfully could incorporate the on-going
active prevention of falls as part of a lifestyle choice, with ultimately no fall being
experienced. Thus, correlating to falls prevention at a simple level, this encompasses
all three proposed substitute perspectives of Successful Ageing: biomedical, as no
physical injury is sustained; psychosocial, as independence is maintained through
continued mobility, impacting positively on self-esteem; and lay-views, productivity
and contributions to life are not thwarted by the ill-effects of a fall.
Both of the models of Successful Ageing introduced above promote ageing through the
life course as optimistic, constructive, and confident. This encompasses a range of
facets of wellbeing comprising all aspects of life – social, physiological, psychological. In
essence, the components of the models of Successful Ageing described above. It is
proposed that no individual would choose to age in any particular negative manner.
‘Life is for living’ and therefore to choose to age with an undesirable social,
psychological or physiological condition is suggested as unlikely. It is acknowledged
that, for some, the circumstances they find themselves in are neither of their choosing
nor desire, for example, an illness or a disease of the body or mind – the pathological
ageing Rowe and Kahn describe. Ageing successfully advocates for adaptions to
behaviour as a means to both attain and maintain maximum enjoyment and
satisfaction from life effectively (Phillips et al., 2010). It implies a quality of life that is
more than reasonable; it is comfortable, agreeable and satisfying.
43
2.7 Chapter Summary
This chapter has provided a review of the evidence base and current thinking regarding
stakeholder perspectives on reasons for and challenges to engaging with falls
prevention. Four key themes were identified: ‘Knowledge and Education’;
‘Communication’; ‘Attitudes and Beliefs’; ‘Interventions’. These themes form a
preliminary conceptual framework which could explain some of the issues facing
stakeholders in relation to engaging with falls prevention. By contrast, an exemplar
model of Successful Ageing has been introduced, which poses the ideal for
stakeholders to engage with falls prevention to assist in securing a fit and positive
journey to older age. This research intends to further understand the challenges to this
ideal, through probing into the four themes identified in the evidence synthesis
through qualitative exploration.
Building on this, the next chapter provides detail on the methodology applied to the
research study, and explains the theoretical perspective of the researcher which
underpins the approach taken.
44
CHAPTER 3: METHODOLOGY, RESEARCH DESIGN
AND METHODS
This study examined the challenges to engaging stakeholders in falls prevention using
qualitative research methods. Following a structured review of relevant literature, this
chapter will now outline the philosophical aspects and methodology which shaped the
design of the study. A detailed description of the methods undertaken and how the
findings were analysed will then be presented.
3.1 Ontology, Epistemology and Philosophical Paradigm
The theoretical perspective takes into account the philosophical principles of reality
which underpin the researcher’s viewpoint during a study. This includes their
ontological and epistemological position, though it is challenging to categorically
differentiate and separate the two topics. Throughout many texts the terminology is
used interchangeably and as Crotty (1998, p. 10) points out, the issues tend to merge
together. As such, it may be said that the two are inextricably linked (Denzin & Lincoln,
1998). Ontology is the study of what is understood; epistemology, how knowledge is
understood (Crotty, 1998; Creswell, 1998). These two positions create a philosophical
paradigm of understanding, which informs the methodology used within a research
study (Crotty, 1998).
3.2 Theoretical Perspective
Qualitative research lends itself to being subjectivist and idealist. Subjectivism is the
individual interpretation and experience of a situation (Silverman, 2010), whilst
idealism takes the view that what is real is limited to how the individual mind
45
understands what is going on around it (Crotty, 1998). An individual’s reality is
therefore specifically linked to their knowledge and experience, constructed according
to how they apply it. This offers the opportunity for examination of individuals’
understanding of a concept, in particular, discovery of the breadth of what is known
and how the concept has come to be interpreted.
Building on the basis of subjectivist and idealist beliefs presents a more classical
research paradigm embedded in interpretivism (Blaikie, 2007). This concept suggests
that humans socially construct their world through perception and interpretation
(Snape & Spencer, 2003). [Snape & Spencer are the authors of the chapter] Each
person will individually view their world and interpret what they see depending on
their experiences, interactions, activities and situations they find themselves in. In the
research capacity, this includes not only how participants interpret and construct their
worlds, but the interpretation of the researcher as they study the participant within
the context of the research study. This is particularly central to the processes of data
collection and analysis. The researcher needs to be clear about their own perspective
and how this may impact on the bearing of the study.
3.3 Methodology
This research was concerned with exploring the challenges to engaging stakeholders
with falls prevention. An interpretive inquiry using qualitative research methods was
designed to build upon existing evaluation work completed as part of a Knowledge
Transfer Partnership (KTP) project (reported in Isaacs, Whittaker, Lyons & Burton,
2011, see Appendix 1). The phase one work, which took place from 2010-2011,
provided the background to this study and offered a critique of a pilot falls prevention
46
programme (‘STEADY on!’), designed for older people and universal frontline staff in
East Lancashire. This evaluation did not provide an insight into participants’
understanding of what a fall is, how they perceived personal risks and whether it was
worthwhile taking or offering preventive action. This meant the earlier phase one
work did not offer an understanding into participants’ readiness to access and engage
with a specifically designed falls prevention programme. The subsequent research,
phase two, was therefore designed as an interpretive study, to enable the examination
of the participants’ perspectives, their experience of falls and falls prevention. This
phase of the study took place 2012-2013. Figure 2 provides a visual outline of the
study design.
Figure 2. Visualisation of the Study Design
To provide insight and facilitate the understanding of the issues in this research, a case
study approach was taken. According to Grbich (1999), the case study approach is a
useful method of both designing and managing the research focus, whilst Denscombe
(2007) recommends that it is appropriate to focus the research design on instances of
47
a particular ‘thing’ to provide an in-depth account of the investigated phenomena.
Stake (1995, p. 86) describes a case study as “not a methodological choice but a choice
of the object to be studied”. Older people are particularly vulnerable to falls and suffer
increased risk and injury from them. As such, they were of primary interest as the
phenomenon of engagement into falls prevention is investigated.
More specifically, Stake (1995) suggests the use of an instrumental case study design
where the study of a case is applied to understand a specific phenomenon. Broadly,
stakeholders are the case being considered to explore engagement with falls
prevention. The stakeholders are contributory to appreciating the challenges in the
acknowledgement and appreciation of falls prevention.
Explicitly in this research, the primary case is the older person aged 65 years and over,
who is studied to gain their understanding of the challenges to engaging such
stakeholders in falls prevention. This is supplemented by the view of an additional,
secondary case, that of the universal frontline staff who work with older people. Each
of the two cases were supported by data from multiple individuals, whose
characteristics formed a bounded system (Stake, 1995). The cases were shaped by
specific contributions and combined features which became, in effect, a whole; a
classification with limits. The bounded systems for these two cases were based on
sample and inclusion criteria, presented in Table 5 and explained in section 3.5.3.
Many authors acknowledge the spectrum of depth and opinions on the strategy, use
and application of case study research (Silverman, 2010; Grbich, 1999; Ragin & Becker,
1992; Schwandt, 2007). In particular, the generalisability of case studies is questioned.
48
In response, it is hoped the design and depth to this study will assist in understanding
stakeholders’ opinions to engaging them, and others like them, in falls prevention.
3.4 Ethical Practice and Governance
The proposal for this work was reviewed and approved by the Faculty of Health &
Social Care Research Ethics Committee, University of Central Lancashire. Approval was
also granted by NHS East Lancashire PCT through their Research and Development
Manager, and the programme manager of the East Lancashire Community Health
Services (Appendices 3-6).
The research took place under the supervision of an experienced team of academic
staff at the university. Regular contact between the research student and supervisors
was maintained throughout the study. Ethical considerations (Beauchamp & Childress,
2009) were discussed thoroughly prior to the design of the study and data collection. A
summary of these is provided in Appendix 7.
3.5 Research Design
The ‘STEADY on!’ evaluation may be classified as a pre-work to this research, a phase
one of the study, for which the second phase employed a two part design. Part one
involved the re-examination of data collected for the ‘STEADY on!’ project, with the
new research question as primary focus. Part two comprised of empirical research with
phase one participants to further explore themes emerging from phase one, and to
probe more specifically about barriers and enablers to engaging with falls prevention.
For clarity of procedure in this section, the methods for each part will be explained
separately as part one informs part two (see section 3.3 and Figure 2).
49
3.5.1 Context and Setting
The earlier KTP project which developed the community based falls prevention
intervention, ‘STEADY on!’ served as background for this study and set the context for
further investigation. The KTP project took place within three electoral wards of the
East Lancashire borough of Hyndburn. These wards had a significant population of
older people with relatively poor socio-economic status, and a higher number of
ambulance call outs to falls episodes.
3.5.2 Phase Two, Part One: Secondary Review of Phase One Data
This work involved secondary examination of data previously collected during the
STEADY on! evaluation. Corti and Thompson (2004, p. 332) suggest secondary analysis
“allows for both reinterpretations and new questions of the data”. In essence, the
reuse or review of data gathered at an earlier time for a different focus. [Corti &
Thompson are the authors of the chapter] Heaton (1998) highlights that secondary
analysis does not prevent further collection of primary data to supplement the
emergent themes from the reanalysis. As a member of the phase one study, the
researcher appreciated the context of phase one data collection whilst simultaneously
understanding the new focus for this phase two study. Absolute ‘analysis’ of the data
was not performed; however a thorough re-examination of the data was completed
through the lens of the phase two methodology and research objectives. See Appendix
12 for an excerpt from this process.
The phase one study had a target population and sample of older people and frontline
universal staff (N=31). The data were scrutinised with the new research question as
the primary focus. Data included field notes and observations recorded during
50
attendance at the pilot falls prevention sessions as an observer-participant (n=12) and
transcripts of semi-structured interviews (n=31) with older people (aged 65 years and
over) and health/social care professionals.
Observations of the falls prevention sessions being delivered to the two target groups,
universal staff and older people, were taken. Consideration was given to
facilitator/attendee interactions, delivery methods and demonstration of resources.
Interviews focused on capturing local intelligence regarding the perception of content,
subsequent awareness of falls risk and alterations in falls related behaviours following
attendance at a ‘STEADY on!’ session. The data was therefore relevant and provided
context and insight to this study, which had a different but related and meaningful
focus.
3.5.3 Phase Two, Part Two: Target Population and Sample
The target group included previous attendees at a STEADY on! falls prevention session,
either as an older person or a frontline staff member of a universal service, and who
had previously participated in the evaluation of the pilot programme (N=31).
The sample was both purposive and convenient; the reason for the initial inclusion of
each participant being their previous contribution to the phase one study. Therefore,
access to and contact with the sampling frame were already established. The sample
were also relevant to the research question, illustrating features of the population
under study. In addition, to access the depth of data required for case study research,
participants from the phase one sample who had been more substantial data sources
were further purposively identified to participate in phase two contributing sufficient
51
data to capably examine and address the research question (not withstanding
opportunity and a willingness to participate). ‘Judgement sampling’ (Bowling, 2009, p.
208) further categorises purposive sampling to include, where selection is made based
on the participant’s knowledge which may be valuable to the research study. Although
talking more broadly about purposive sampling, Stake (1995) argues this is acceptable
as it maximises what might be learnt, especially within the boundaries of practical
issues associated with research - time, access and resources.
Silverman (2010) discusses critical thought being put into the criteria of the study
population. Stake (1995, p. 2) explains a case as a “specific, complex and functioning
thing”. Stake continues by incorporating Smith’s “bounded system” into his description
of a case, where clearly defined limits or features which make the case distinctive are
identified. It is suggested that this may be subtly linked to the “parameters” of the
sample Silverman (2010, p. 141) mentions. As such, the sample criteria/case
boundaries for this study are presented in Table 5.
Older people Frontline staff
Aged 65 years and older Work for a health or social care, voluntary, statutory or charitable organisation
Reside with the Hyndburn locality Work directly at the frontline with older people aged 65 years and over
Those who self-select to attend services provided within the Hyndburn locality
Provide services to older people within the Hyndburn locality
Previously attended a ‘STEADY on!’ session
Previously attended a ‘STEADY on!’ session
Participated in the phase one study Participated in the phase one study
Table 5. Sample Criteria/Case Boundaries
52
Sample sizes of four participants per case were originally anticipated, with a
recognised gender bias towards the female population due to the demographic of the
‘STEADY on!’ sessions and phase one study.
3.5.4 Part Two: Recruitment
Contact was made with a sample of phase one participants via telephone and a short
introduction to part two of study was provided. If participants were happy in principle
to proceed, an information sheet (Appendices 8 - 9) about the study was sent out to
the participant. No less than one week later, a second telephone call was made to ask
if the participant had received the information and if they had any questions. The
participant was then asked if they were happy for an interview appointment to be
made for a time and location convenient to them. At the time of the interview
appointment, the participants were asked if they had any further questions about the
study before signed consent was obtained (Appendix 10). Participants were reminded
that they were free to withdraw from the study at any time, without giving a reason.
3.6 Data Collection Methods
Semi-structured follow up interviews with participants were the method of data
collection. Broad questions were used to introduce areas for discussion, as Legard,
Keegan and Ward (2003, p. 148) call “content mapping”, and then a number of probing
questions were used to “content mine” to get deeper into the participants’
understanding of topics (Legard et al. are the authors of the chapter). Based on the
conceptual framework developed from the literature review and part one secondary
review of phase one data, an interview schedule was proposed (Appendix 11). This was
53
used during the interviews not a regimented agenda, but a prompt sheet for the
researcher to ensure all core themes were addressed.
A conversational style of interview was adopted by the researcher which, coupled with
the prompt sheet, provided the semi structure whilst also allowing freedom to
navigate the discussion based on responses by the participant. Therefore, in-depth
interviews were conducted, which are most useful as a means of gaining and
representing information from the case (Stake, 1995). The interviews lasted between
30 and 100 minutes each. With permission, all interviews were audio recorded and
then transcribed verbatim. The audio recordings were then all destroyed. To
supplement the interview data, field notes were maintained and recorded within a
short time frame of the interview concluding. These were used as the basis for the
case descriptions, as per the standard for case study reporting (Creswell, 1998).
3.7 Data Analysis
Data were thematically analysed following a process described by Miles, Huberman
and Saldaña (2014). Throughout and after collection, data were reduced, displayed and
verified. Reduction involved selective transcription of both hand written notes made
during interview and audio recordings. When transcribed, the data was segmented,
coded and allocated to categories using colour blocking, post-it notes and flip chart
paper. This was an iterative process which allowed further reduction of the data until
solid themes emerged across all the cases. To achieve this, each transcription was read
and re-read, the detail analysed and key phrases highlighted. This facilitated
confirmation and validation of themes and concepts. Appendices 13 – 15 provide
examples of notes made throughout this process. Appendix 13 shows reduction of part
two data; Appendix 14 provides an early visualisation of the part two analysis;
54
Appendix 15 displays a ‘notes extract’ exploring an emerging theme. The grounded
theory principle of theoretical saturation (Glaser & Straus, 1967) was drawn upon to
help determine the point at which to draw the search for additional themes to a close.
The process was iterative, with feedback and guidance on the direction of analysis
pursued with supervisors at regular intervals.
3.7.1 Analytical Style and Reasoning
It was originally anticipated that the research would be approached using combined
deductive and inductive methods. Deductive reasoning involves theoretical
explanations being generated in advance of the data collection, whilst inductive
reasoning allows a theoretical proposition to develop out of the data (Mason, 2002).
The phase one study and examination of the literature for this study led to the
identification of broad themes or challenges to engaging stakeholders in falls
prevention. The conceptual framework was developed and used deductively to guide
part two data collection and analysis. This analytic style was suitable to a point and
served as a valuable learning experience for the researcher. However, through
discussion with the research team it became apparent that whilst the data fit the
conceptual framework in the broadest sense (see section 5.1), the data had more
depth and complexity. It required re-analysing using inductive methods to facilitate a
more rigorous and quality research study, out-with the confines of using the
conceptual framework. The analysis process was restarted afresh without
preconceived themes and concepts from previous stages of the study guiding the
process, but rather the data providing the emergent story.
55
3.8 Data Protection and Anonymity
All data were stored in accordance with the University of Central Lancashire policies
which are compliant with the Data Protection Act (1998).
Any material which identified study participants was kept separate from study
transcripts, which contained a coded reference to the participant. Paper based
research data was kept in locked cabinets whilst electronic data was stored on a
password protected computer or password–protected, encrypted USB stick. All audio
recording were destroyed once transcribed.
Throughout the thesis, pseudonyms are used to refer to study participants, their family
members, and professionals involved in their care. These names have no
socioeconomic or other reference purpose.
3.9 Chapter Summary
This chapter has described the interpretive theoretical perspective and methodological
principles of case study research which guided and shaped the approach to this study.
Building on an earlier evaluation study (phase one), the design of the study (phase
two) was defined as comprising two parts. Phase two, part one involved secondary
review of phase one data. Phase two, part two included empirical data collection using
in-depth semi structured interviews. The target population, sampling and recruitment
methods were described, together with consideration of ethical and legal obligations
and the process of data analysis undertaken. The findings from this analysis are now
presented in the following chapter.
56
CHAPTER 4: FINDINGS
The previous chapter presented the case study methodology used to guide this study:
an exploration into factors that may affect stakeholder (older people and frontline
staff) engagement with falls prevention. The methods by which data were gathered
were discussed and the data analysis process described. In this chapter, the findings of
the empirical research which formed part two of the study are presented. These
sought to address three objectives:
i. Explore beliefs and opinions of the stakeholders about what a fall actually is.
ii. Identify barriers and enablers for stakeholders to acknowledge and value falls
prevention.
iii. Explore the opinion of stakeholders on opportunities and challenges to
participate in community approaches to falls prevention.
The cases are first introduced, followed by an overview of the findings and then a
comprehensive exploration into the key themes and sub themes identified. Where
data are presented, all personal identifiers have been removed. If individuals have
been referred to by name, these have been changed in accordance with the data
protection policy to protect anonymity at all times. The use of italics denotes a quote
from a participant.
4.1 Phase Two, Part One Outcome
Supplementing the conceptual framework of four themes developed during the
literature review, part one concluded with a potential fifth theme emerging (Figure 3).
The distinct need for follow-up interviews with participants was also recognised. This
57
would enable a more focused inquiry into the research, by assisting in clarifying and
further exploring related issues which were mentioned but not probed in the STEADY
on! study.
4.2 Phase Two, Part Two: Introducing the Cases
As per the study design, the stakeholders are separated into two cases. Case One:
older people aged over 65 years and Case Two: universal frontline staff who work with
older people.
The characteristics of the two cases studied are provided below. The socio-
demographics of both case participants’ (N=11) are summarised in Table 6.
4.2.1 Describing the Older People’s Case: Case One
The older people aged over 65 years (N=6) are mostly female (n=5). In one instance a
participant’s husband also consented to joining the interview. The Case One
participants (referred to as Stakeholders 1 - 6) range in age from 75 to 84 with a mean
age of 80, and all indicate they are of White-British ethnic origin. Two participants
made no disclosures of falling, whilst the other four had experience of between one
and an uncountable number of falls within the previous 12 months.
Intervention
Communication
Knowledge and Education
[Support]
Attitudes and Beliefs
Figure 3. Conceptual Framework Following Secondary Review of Phase One Data
58
Case One - Older People Case Two - Universal Frontline Staff
Participants 6 Participants 5
Sex Female
Male
5
1
Sex Female
Male
4
1
Ethnicity White British 6 Ethnicity White British 5
Organisations Represented 5
Age
75-79
80-84
3
3
Work roles
Review Assessment and Support
Officer
Occupational Therapist Support
Volunteer
Scheme Manager
1
1
1
2
Table 6. Overview of Interview Sample
This remained unchanged since the phase one study. Four of the six participants reside
in sheltered/ supported accommodation. One participant owns their accommodation,
the remainder all rent. All participants are mobile, albeit one with a frame and two
using walking sticks as mobility aids. Table 7 offers individual description of the Case
One participants. Further descriptive narrative is provided in Appendix 16.
4.2.2 Describing the Universal Service Staff Case: Case Two
Five organisations and four job roles are represented by the universal frontline staff
participants (N=5). One participant is male, the remaining four female. The staff have
worked with older people for between 18 months and 25 years. No staff have changed
roles since phase one of the study. The participants in this case work with older people
aged over 65 years on a daily basis (n=4) or weekly (n=1) basis providing health and
social care and support both in the older peoples’ own homes and community settings.
All participants have previously attended STEADY on! training sessions.
59
Case One: Older People
Participant Age
(years)
Living
Arrangements Additional Detail
Phyllis 75-79
Alone in sheltered
accommodation
flat
*Diabetic, uses a walking stick for bad hip
*Has never, touch wood, fallen.
*Leads an active lifestyle, out everyday
*No domiciliary/homecare support
Penny 80-84
Alone in sheltered
accommodation
flat
*Physical disability since childhood, also
suffers arthritis
*Fallen within 18 months
*Gets by with her carer, son and some
very good neighbours
*Recently bought a walking stick
Paige 75-79
Independently in
privately owned
home
*Suffers arthritis in most joints
*Recent knee replacement-awaiting
second
*A number of falls within 12 months
*Uses some home adaptations
Pattie 75-79
Alone in sheltered
accommodation
bungalow
*Hard of hearing, suffers a number of
ailments
*Has pendant alarm kept at bedside
*Receives domiciliary care daily
*History of falling-3 within past 6 months
Peggy,
Percy
80-84
80-84
Private residential
first floor flat
* Percy suffered a stroke 18 years ago,
now walks with stick and home
adaptations
*Both mobile and active in community
*No falls themselves for a long, long time-
often help neighbours who fall
Table 7. Case One: Participant Stakeholder Descriptions
All indicate that although falls are a particular issue for their client groups, they had
not received any other training on falls prevention prior or post the STEADY on!
session. Table 8 offers individual description of the Case Two participants. Further
descriptive narrative is provided in Appendix 16.
60
Case Two: Universal Frontline Staff
Participant Role Additional Detail
Simon Day centre Volunteer
*Retired engineer, volunteers 1 day/week
*Duties include conversing, mobilising and
generally assisting older people
*Speaks of personal and professional issues
with falls prevention
Sandra Review, assessment and
support Officer
*Worked with older people for many years
*Often involved after a fall has occurred-
speaks of the impact of falls
*Experience in completing falls risk
assessments
Sally Sheltered accommodation
Scheme Manager
*In role for over 10 years
*Witnessed physical and psychological
effects of falls
*Likes to ensure the most appropriate
support given to older people (tenants)
Susan Sheltered accommodation
Scheme Manager
*In role for 25 years
*Wishes to develop good relationships with
older people (tenants)
*Co-ordinates speakers at residents
request-falls prevention never suggested
Sarah Occupational Therapist
Support
*Community based for almost 10 years
*Describes feeling lumbered with falls
prevention
*Most frequently sees older people post-fall
Table 8. Case Two: Participant Stakeholder Descriptions
4.3 Describing the Data
Proceeding the interviews and preceding the in depth analysis, the data were
examined collectively. A number of general but salient descriptive points were
identified, as listed, and further detailed below.
i. There appears no common agreement about what constitutes ‘a fall’
ii. Resignation to accepting and expecting falls as part of ageing is mooted
iii. The outlook upon falls and the future differs depending on falls experience
iv. A prevailing focus on extrinsic falls risks is noted
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v. Falls prevention is challenging – there are no easy answers to engaging people
i. There is no common agreement about what constitutes ‘a fall’
According to the literature, a fall can encompass a slip or trip which results in a person
descending to the ground. However, as Sandra and Phyllis illustrate, there are various
perceptions of what a fall is.
Sandra – It’s when they’ve actually hit the ground and they’ve fallen and can’t
get back up again. A lot of them, if they do manage to get back up again they
don’t somehow class that as a fall – they’ve just stumbled.
R 1– So a stumble isn’t a fall?
Sandra – Not in their view, no
R – What if they slipped out of a chair to the floor?
Sandra – They wouldn’t class that as a fall either…they have to have physically
fallen over and hurt themselves [pause] and need some help.
For Sandra, the essence was being hurt and needing help. However Phyllis, when asked
the same question, “What do you class as a fall”, offered a different, slightly broader
perspective.
Eee, well, having not done it I don’t really know what it’s like. The man across
here, he fell, had to get the ambulance for him. There’s a few here who’s fallen
in their flats….. they just end up on the floor. Now they might slide too. Yes, I
think that’s like a fall.
Although an ambulance is mentioned, unlike Sandra, Phyllis doesn’t refer to being hurt
or needing help. Rather, the principle of ‘being on the floor’ is the fall identified.
1 R denotes researcher dialogue
62
ii. Resignation to accepting and expecting falls as part of ageing is mooted
There appeared an inference or assumption that as people age, falling is an analogous
part of the ageing process. Some participants explicitly stated this; the older you are,
the more you may fall (Phyllis). Others, like Susan described their thinking more
delicately.
It’s like Betty2, living at home, gradually getting older, getting slower, and as we
all grow older, changes happen, and well, this is how it is now. You know so I
wonder if they ever think there is anything that can be done because this is how
my life is.
The participants didn’t consistently provide or identify a reason as to why they or
others had fallen – they just didn’t know why and therefore the cause of the fall was
unknown. This relates to the ‘accidental’ nature of falls, something that wasn’t planned
or done on purpose; it happened by chance. This gives a mixed feeling about what can
be done to prevent falls, if there isn’t always a reason for them to happen.
I fell outside of the door here. You know, for you, it might sound strange but I
can’t tell you how or why I did it. (Penny)
R - What do you think you do to prevent falls?
Peggy – Well I don’t know, because I try but they just happen. I mean, I fell out
of bed not so long ago [voice alarmed] …. (Peggy)
Through expecting falls to happen, the sentiment has a two-fold perspective. For the
older people, this involves the privacy of falling, the embarrassment, the frequency
and the resignation or submission to falling. The issue is too personal or so inevitable
that it’s not worth addressing. Pattie was talking about a recent experience of a fall.
2 Arbitrary name
63
R – Have you thought about contacting anyone in the NHS about your fall?
Pattie – No .... [shakes head]
R – Can I ask why that is?
Pattie – Well, I just think they must happen to everyone – what can they do
R – So you don’t feel there is anything that can be done?
Pattie – No
For the universal staff, as Simon discusses below, an acknowledgement that older
people fall more than is widely recognised, however there is not the capacity, the
answers, or the resources to direct action to preventing them, again, resigning them to
the inevitability of falls.
I think there were some figures given about admissions to hospital resulting
from falls but I couldn’t remember them. But I also think they’re far more
frequent than people realise. And people don’t admit to it either, do they?...... I
think it’s a hell of a lot more prevalent than people realise. [Pause] …. It’s all
very complex when you start to think about it, isn’t it? (Simon)
iii. The outlook upon falls and the future differs depending on falls experience
People of any age can fall, however the nature of the interview, the resilience inferred
and attitude towards falls changed negatively if the person had experienced a fall. For
some this wasn’t necessarily indicated in what they said, rather their tone and
demeanour in the way they spoke about their experience.
Phyllis – I’ve just been lucky up to now.
R – How do you mean lucky?
Phyllis – Well, I don’t do anything special if that’s what you mean, I just have
nay fallen up to now [laughs]. (Phyllis)
Phyllis takes a lighter hearted view having not experienced a fall. As Simon suggests, I
don’t think you actually think about falling unless you’re a regular faller.
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The physical and physiological impact of falling are only really understood when they
have been experienced first-hand, as Percy and Sally offer insight to.
I never thought about it, never fell, never thought about it, and then well, it
started to happen, you see, and then I had to start trying to avoid it because
well, it hurts, yes, it hurts!! (Percy)
When someone falls it just really knocks their confidence… after that I think they
are more cautious, they take more notice. But they become, you know, a bit
complacent if they haven’t fallen. (Sally)
iv. A prevailing focus on extrinsic falls risks
Generally the participants gave the impression of a lack of understanding about what
the range of falls risks are and what can be done to try and prevent falls occurring.
I don’t think people understand. I mean my husband; he was always a
sportsman, looked after himself and then went right unsteady on his feet. He’d
always been fit [pause] we didn’t understand why he should be like that. I
couldn’t understand what the problem was. I thought he wasn’t trying. That
was hard, and I were younger then too, I didn’t know about falls myself.
(Paige)
The practical side of falls prevention, altering and adapting the physical environment
was appreciated and discussed more by all participants. For the older people, it was
about their home space: no clutter; few rugs; keeping it tidy. The predominant
approach identified involved taking personal care, implying a sense of personal
responsibility.
R - Anything that would make you more likely to engage with falls prevention?
Penny – I can’t think of anything… It’s just a case of be careful, as careful as you
can be!! (Penny)
65
Peggy – We’re very careful.
R – Can I ask what you mean by careful?
Peggy – Always look where we’re going, same outside. You’ve got to…. you’ve
got to be careful with what you’re doing. (Peggy)
Universal staff are obliged by the requirements of health and safety legislation to
address these external risk factors that presented as physical hazards.
Some of them did have welcome rugs at their front doors, and they were made
to move them. I told them all to move them because obviously, if there’s a fire
or whatever and they come and trip over the mat or other residents are walking
down the corridor and the mat has moved out, then that’s a potential hazard
for other residents as well. (Sally)
When probing further, as with Sally, intrinsic risk factors such as medication and co-
morbidities were not generally recognised nor appreciated as being risk factors to falls.
R – You’ve mentioned environmental falls risks, such as carpets. What about
other falls risks?
Sally – What do you mean? (Sally)
Using the services of the local NHS was the most frequently described falls ‘service’,
but this was usually when the participant was referring to a period after a fall had
occurred. For practical and environmental risks, occupational therapy and local ‘handy-
man’ type services were mentioned in both a prevention and reactionary context by
the universal staff who had worked with older people for a lengthy time and had
responsibility for health and safety as well. It was frequently mentioned that until the
‘STEADY on!’ project, the participants hadn’t been aware of the local community falls
prevention service offered by the Primary Care Trust. Even though other agencies were
66
mentioned in that session, such as the local charitable and council agencies, fire
brigade, pharmacists, opticians and so forth, these were not recalled during the
interviews for this study.
R – Where would people go to find out more about falls prevention?
Phyllis – No one ever talks about it. No one ever talks about it here, anyway. So I
don’t know where you would go about it. (Phyllis)
R - If you or your colleagues wanted to find out more about falls prevention,
where would you go?
Simon – The manager first…. And then where would he go? The internet?
R – And the older people in your care?
Simon – Probably the carers they have at home, or their sons or daughters.
Relatives if they have any. (Simon)
v. Falls prevention is challenging – there are no easy answers to engaging
people
Appealing to people to participate and learn about falls prevention is, as Simon says, a
difficult thing…. switching people onto it. There is a fine line between what should be
shared, what could be shared, and how to go about it. As he continues,
If you are there, you’re boring them; if you talk about what might happen,
you’re frightening them. You’ve got to work out in between what you want to
do. (Simon)
The individual participants all referred to personal preferences about how they like to
have information delivered to them.
Pattie – Well I read lots, I like reading, keeps my mind going.
R – So you would read information about falls prevention then?
Pattie – Well that would be alright, wouldn’t it, if you had it? Have you got it? I
mean I did when I got the cancer, I had lots to read; what to do, what not to do ,
67
it were right helpful… and there were numbers on if you had any queries, you
could ring that number. I mean what more do you want?
(Pattie)
Similarly, Penny mentions how I can always refer back to them, you know, written
things…. You can go back and read it again, double check, if the need arose. Memory is
going too [laughs].
Yet Paige offers the view that showing them [people], like you did [the STEADY on!
session]…. you can learn a lot, was preferable over leaflets. Simon supports the latter
with the following appraisal of leaflets.
You can give leaflets out until you’re blue in the face and you might get
something like 25% read it and understand it, 25% read it and don’t understand
it and 50% who won’t even bother reading it. (Simon)
Sally offers a view with a compromise between leaflets and a session.
You can try meetings and hopefully, hopefully people will come. But like I said
before, not the younger ones. I don’t think they see it as a major thing. It’s not
relevant to them. Perhaps like leaflets or something if they had one through the
door they might read it, it might just make them think about it. (Sally)
4.3.1 Data Summary
From this descriptive review of the data, it appears as though the participants all know
something about falls. More seems known about what it is to fall, having experienced
or witnessed it at some point in their lives (if not in their recent or older years). Less is
conveyed about the hazards and risk factors to falling, and the help and assistance that
68
are available to try and prevent falling. Identifying strategies to engage stakeholders in
falls prevention is perplexing.
Within this descriptive array, a number of emerging themes are identified. As detailed
in the previous methods chapter, these were abstracted, conceptualised and
considered against the breadth of data and the framework developed following the
literature review. The analysis was honed to specific focuses of understanding and
concepts, thereby reducing the data. Data display techniques were used to aid this
process, and furthermore to draw conclusions and verify the suggested concepts into
key themes and sub themes. See Appendix 13-15 examples of this in relation to the
dataset.
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4.4 Key Themes
The detailed, in-depth data analysis presented three key themes; ‘Age’, ‘Experience’
and ‘Support’. Figure 4 illustrates the order in which these will now be examined.
4.4.1 Ageing
This theme explores aspects
associated with getting old
and how the self-concept a
person upholds can impact on
their attitude to falls and
prevention.
‘Younger Old’ or ‘Older Old’ Person
The participants of Case One implicitly identified themselves as a sub-group of the
elderly population: the ‘older old’ ones, those a little less mobile and perhaps more
frail. This was borne out by Case Two participants explicitly introducing the phrase
Age
'Younger Old' or 'Older Old' Person
Acceptance and Capability
Image and Identity
Fear
Figure 5. Illustration of Key Theme ‘Ageing’
and Sub-Themes
Age
Experience
Support
Figure 4. Key Themes Identified from Phase Two Data
70
‘younger old’ ones when they referred to those within their care who were more
active, independent and nearer 65 years in age than their counterparts.
A Case One participant, despite managing to get out every day, spoke about the new
ones [residents] in here [the residential complex].
Some of them have cars, so they go out in them. They’re [the new residents]
more independent, younger - out and about more. (Phyllis)
Without overtly positioning herself as an ‘older old’ person, the conjecture is made
towards there being a difference in the participant’s personal situation when
compared to others. Conversely, Case Two participants were distinctly clearer in their
differentiation across the elderly population. Speaking about a line dancing session
that used to be available, Sally split the resident dancers into a few of the older ones
that are active…and a lot of the younger end. Similarly, Sandra discussed the high
proportion of quite elderly people over 80 in their care; ….quite an older age end really.
Although collectively known as ‘the older generation’ which in health service terms
generally indicates all people aged 65 years and over, older people themselves appear
to identify a spectrum of older age which is split into these two distinctive subgroups;
the ‘younger old’ and the ‘older old’
Acceptance and Capability
Acknowledging that falls are something that an individual may be more susceptible to
because of their age, requires the person accept the fact that they are getting older.
For many people, but perhaps a ‘younger old’ person in particular, this is a prospect
that they may not wish to face or concede because, as Pattie states, life is not likely to
71
get better than it is, or has been, only worse. The self-perception and acceptance of
ageing is personal to each individual: it is about how a person realises and admits that
they are ageing, and beyond that, what it means to them in how they continue to live
their life.
Case Two participants recognised this in an objective manner when thinking of those in
their care, but subjectively when thinking of their own personal circumstance.
I think that if I was a little infirm I don’t think I’d always want to have to ask
someone to help me. It’s the independence of at least trying to do something
for yourself and then you go past your boundaries. And then you might fall. But
these people in here are quite good at it. If they want to go somewhere, they’ll
ask you… very few of them try and stand on their own, let alone go anywhere
on their own. (Simon)
Here, Simon introduces one of the issues with accepting a decline in age and ability –
the need to rely on other people for sometimes the simplest of things. It may seem
easy to talk about knowing ones limits and those of others, to appear accepting of
what age means you can or cannot do as indicated above when speaking about how
the older people are good at it. However, when thinking specifically about how this
impacts directly on his own life, the thought becomes harder for Simon as he
recognises the quandary between accepting his situation and taking preventative
assistance, and becoming more dependent on others.
Toying with acceptance of ageing was a subtle but constant theme throughout Case
One. The mantra life’s too short was mentioned by Pattie, together with there’s plenty
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out there worse than me [speaking about age-related comorbidities]. She then went on
to acknowledge her limitations.
I want to do the top of me cupboards but I know I can’t reach, so I don’t do. I’m
bound to fall if I were to [laughs].
The nature of Pattie’s quote suggests recognition of the hazard, her situation and an
outcome she wishes to avoid. Despite wanting to do something, she is resigned to not
doing it because she is accepting of her age and ability. The joviality though is perhaps
a way of coping with this predicament.
Recognising and accepting that an individual is ageing creates a parallel requirement
for recognition that the older person is perhaps not as physically or mentally capable
as they once were. Paige emphasised this point when speaking about her history of
falling.
What really scares me is that I can’t get up. I can’t get to my knees to get myself
up. When you’ve got bad knees you can’t go on your knees…… see I’ve not the
strength in my arms. I suppose I have arthritis everywhere.
What is described is a medical condition which severely impacts on the individual’s
ability to get herself off the floor once fallen. The effect is on her physical self, being in
a virtually immobile position, but also mentally, as she mentioned being scared.
For those working with older people, as per Case Two, a different perspective on
capability is given. The viewpoint has a lesser expectation of what the older people are
able to do, and an assumption that this is where the role of the worker is to step in.
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Everyone here is conscious of the type of people we get here, as they are
themselves. They [the older people] might try and do more if they were on their
own but here, they’re not allowed to move without our assistance.
(Simon)
Within this quote, the type of people indicates that a distinction is made in age,
mobility and general capability. The phrase “not allowed to” is also quite striking in this
extract. Having observed the environment in which the care takes place (non-
residential), the action is not as severe as it sounds. It is intended as a caring address to
ensure that none of the older people come to any harm, through falling or otherwise.
However this could potentially have a paradoxical effect of learned helplessness, which
is again inferred in the quote, “They might try and do more if they were on their own”.
This intimates socialisation into the older peoples’ role of being cared for.
Both acceptance and capability can form a substantial part of how an older person
sees themselves, how they wish the outside world to see them, and how the outside
world actually receives them.
Image and Identity
Whether intrinsically accepted or not that an individual is getting older, the external
image that a person wishes to uphold to the rest of the world may be an important
one, and one that supersedes engaging with falls prevention initiatives. Pattie
discusses a recent fall and how she felt about it:
And I were in a shop… and whoosh, down I went… Hurt me knee then. I mean
they [the shop people] were nice but oh [pulls face] it were awful, I were
horrified. (Pattie)
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Sandra made a personal reference to the initial reaction she felt from experiencing a
fall in her personal life.
Pre interview, discussed jogging with Sandra – she mentioned she had slipped
whilst out jogging last week – no harm or injury but she was thankful no one
around to see – embarrassed. (Field Notes)
From the position of both cases here, reference is made to both the personal and
public impact of the fall: how the individual feels within themselves and suggesting
how they feel they may be perceived. It is acknowledged that this is viewed across
both Cases and therefore a wide age spectrum.
Discussing an older resident, Sandra introduced another example about the use of
walking aids and their impact on image and identity.
One lady at the moment, she’s always been in very good health but her health’s
not as good lately. In fact she’s been quite poorly and I wanted to put a referral
through for a frame for her because she’s not as steady as she used to be. She’s
absolutely adamant it’s an ‘old ladies’ thing and she’s not having it. She’d
rather just sit in her chair than having something to support her to keep her
steady..… Her family have had the same argument with her. They wanted to
take her out last week in a wheelchair, you know, just take her out, build her
strength up, mentally and physically. And she wouldn’t let them take her out in
[the local town] in the chair. She said, “If you take me out, take me to a place
where nobody knows me”. She’s 70-odd as well, so she’s not 21 and not
wanting to be seen with this frame or that chair!
There are a number of factors which are highlighted here: the recent onset of poorer
physical health leading to deterioration of physical capability which is recognised by
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others, family and formal support personnel but a resistance to accept this changing
situation by the lady herself. It appears that her image is of most concern to the lady:
how she is seen by the external world and what that says of her and her circumstance.
She does not want to be seen as an ‘old lady’, despite her age and state of health.
There appears to be an emotional aspect to adjustment to her physical situation which
she could be resisting. It could further be suggested that she is prepared to forego
some aspects which may contribute to her enjoying a better quality of life, such as
using the support system around her to get out and about into her local town which,
as suggested in the quote, would be beneficial to the lady’s physical and mental states
of health. The bold refusal to have a frame to assist her mobility even in a closed and
private home environment amplifies the complexity of how the image the lady holds of
herself is a barrier to her engaging with falls prevention. This could be further
unravelled to the self-concept the lady holds about herself, how accepting she is of her
current situation and how she can assert control in this small area to maintain being, at
least to herself, the person she is in her mind’s eye.
Once a fall has occurred, depending on the severity of injury suffered, an unknown and
unfamiliar future may become a prospect. For this and other reasons, when older
people fall they do not always share the fact they have fallen with anyone. As Paige
said about a fall experienced in the garden and alone,
Paige – I felt silly… They said I should have gone [to hospital] as soon as I’d done
it, but well, I felt silly.
Researcher – Is that why you didn’t tell anyone?
Paige – No, no, no. I just don’t tell people things like that. No, I just kept it to
myself.
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This last statement is interesting because Paige goes on to talk about other ailments
suffered, to the point where “sometimes I think that they think you’re neurotic, what
with everything” when going to the Doctor to discuss them. All Case One participants
spoke about co-morbidities, some of which would have an increased bearing on
susceptibility to falls, and yet no one had recalled having been asked by their doctor
about falls or advised about falls prevention.
Case One participants didn’t particularly share why they don’t talk about their falls,
because as Penny explains, it’s not the usual thing you share with your friends….. you
just don’t. Case Two participants appeared quite clear about the reasoning. Susan
stated that no, the majority of older people don’t share the number of falls they’ve
experienced, and highlighted two points in particular when asked further about this.
They don’t want to be seen as vulnerable, and they fear losing their
independence in the community.
This insight from the Case Two perspective emphasises fear in relation to support and
dependency in particular.
Fear
Before a fall, the consequences are not known, but it is anticipated that falls are not
pleasant experiences for anyone of any age, as Simon points out:
It’s everybody’s health and safety if you can prevent somebody falling over,
banging their heads or breaking bones. And especially when you’re older and
your bones are more brittle, aren’t they, it saves an awful lot of pain….. Stop the
pain, because if you hurt yourself, it hurts.
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Falling can cause physical pain, from a bruise through to a broken hip. If pain is feared,
it could be assumed that people may endeavour to avoid the possibility of
experiencing that pain. The ‘fear’ could push people into trying to prevent falls as
much as they possibly could, through learning about what they could do and
interventions available. However, at times, quite the opposite occurs, as Simon
explains.
If someone comes along and says.. “We’re here to talk to you about falling”..
Everyone moans and groans, “Oh, I don’t want to know anything about that…”
You know, because it’s a frightening thing as well as anything else…… It’s hard,
hard without frightening people. You could frighten people…. It’s a difficult
thing, switching people on to it.
People don’t want to know about what ‘might happen’ to them. Speaking in a different
context, about the value of ‘good company’ in a social setting, Pattie makes a similar
observation:
That’s what you want though, company like that to make your day. Or else you
come home and you start thinking about all those poor souls less off than you,
all those things that could go wrong. It’s not what you want, it’s not good for
you.
There seems to be a crux where the causes of fear appear head to head and in conflict
with one another. The fear of falling and wanting to do all to prevent the fall, set
against frightening thoughts of what might happen, the ‘what if’ and not wanting to
dwell on the negative prospect.
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Theme Summary: Age
In the Case of Older People, ‘Ageing’ is a prominent theme, with acceptance of age
seeming pivotal in older peoples’ reconciliation with the need to engage with falls
prevention. As the effects of ageing occur, continuing to live the life that the person is
used to may no longer be possible. Both Cases acknowledge that older people can be
subtly categorised into ‘Younger Old’ and ‘Older Old’ people through the capabilities
and image displayed. Case One participants infer quite subjectively that acceptance of
age and as such, their identity is relevant when thinking about falls prevention, and
how its engagement is perceived by others. Case Two seemed more objective in their
appreciation of age, and mindful of the need and benefit of falls prevention to the
older population. Despite acknowledging falls as a risk, the connotations of engaging
with falls prevention appears synonymous with being old, and in particular, an ‘Older
Old’ person. For this reason, whilst falls prevention may be recognised at some level, it
does not appear fully acknowledged or truly valued.
4.4.2 Experience
The experiences of falling described by
the participants appeared to impact on
their engagement with falls prevention.
This section explores this proposed
relationship depending on whether the
stakeholder has fallen or not and based
on the fall, where the responsibility for
the experience lies.
Experience
The Fallen
Reason and Blame
Taking Care - Taking Risks
The Lucky
Figure 6. Illustration of Key Theme
'Experience' and Sub-Themes
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The Fallen
Over half the participants (of both Cases) described situations where they themselves
had fallen. The circumstance and type of fall varied, with different consequences and
injuries for each (corroborating the heterogeneous nature of falls), but the overall
experience had altered the attention the participant has since paid towards trying to
prevent another fall; increased vigilance.
In a discussion about her experiences of falls, Penny described how a stumble shook
me up and following in the incident she has tried to avoid it [the cause, though
unknown], not to make the same mistake again. When probed, the cause of the
stumble couldn’t be ascertained, but the legacy of the incident is a more wary,
cautious person who doesn’t want to experience the same or worse again.
If you know what’s happened, what might happen, you think right, I’ll be more
careful next time. (Penny)
Pattie highlighted the importance of watching what you’re doing more, in reaction to a
recent fall.
I’m more observant of things. I mean, since I hurt me leg tripping over that
suitcase. I’m watching out for things like that. I’m looking making sure there’s
nothing in my way. I observe more, I can say that! (Pattie)
And in another recent instance,
I was getting off the bus last week – I thought the bus had stopped but he
hadn’t so I went down then. Bruised me back and me bottom…... I don’t know
why I jumped up to go when I shouldn’t have. I won’t do that again.
(Pattie)
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Whether the experience is a stumble, a trip or an outright unforeseen descent to the
floor, having a fall can heighten the awareness of the person about hazards and risks.
Taking Care - Taking Risks
Some Case One participants indicated that the experience of falling could determine
and influence how they ‘take care’ of themselves in their approach to falls prevention.
Pattie recalled an example of this about a falls risk which she was unaware of until an
incident occurred.
Well, you see, you know those stoppers, the rubber ones on the end of your
stick. No one ever told me you had to change it. And I were in a shop and I lent
on the stick and whoosh, down I went. I didn’t know you need new ones every
now and then. I know now.
However Percy suggested that he was automatically quite risk aware.
We don’t allow anything to remain on the floor for any length of time. Just in
case we trip up or something. I’m very careful on that one.
And when we’re ‘hoovering’, we have a cylinder hoover, and the wire goes
along the floor. We’re both very conscious of the wire being on the floor.
In this, the household chore of ‘hoovering’, which may present a hazard and
accentuate the risk of falling, is reduced by the specific attention paid to where the
hoover wire is laid.
For those who have not experienced a fall in a particular situation, to some, they might
appear to be risk-takers. Penny references the way that other residents just don’t see
things the same, they’re just not interested. They don’t think falls will ever happen to
them. The intimation is that the other residents are taking risks, though perhaps not
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deliberately, but risk taking all the same, and won’t listen to reason as to why they
shouldn’t.
The way they go up and down those stairs… I don’t think they think it [falling]
would ever happen to them… and off they trot! (Penny)
Depending on experience, and other associated factors, people have different
perspectives on what the hazards are, what the risk is to them and how they should
then approach the ‘risky’ situation. Some may choose to apply practical common
sense.
Any information [about falls risks] is always helpful. Makes you sensible. I don’t
know where some people get their ideas from but they need a bit of common
sense from somewhere. A bit of common sense, yes. (Peggy)
Peggy is referring to using sound judgement in practical matters, and paying attention
to the obvious. That is, if something appears risky or is a known hazard, then behaviour
is changed to reduce the risk. However the sense applied may be different, depending
on individual perspective, experience and known capability as Penny describes;
No two people are quite alike. I’ve definitely found that out in here. Some
people do things that I think, well, I’d be on the floor, or falling down the stairs,
hurt myself anyway. But they just carry on doing it. It doesn’t seem to worry
them, the risk.
The key feature of this data is the apparent indifference of some people for what the
participant clearly views as a falls risk. Although only speaking with knowledge of her
own situation, she infers that using common sense is challenging for some with respect
to preventing falls.
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Reason and Blame
When a fall has occurred, the cause of the fall is often sought. As it is rarely an
intention to fall purposefully, the reason for falling is considered, often with the
assignment of blame to the source.
Blame attributed to pavements by Case One is a recurring example of this. This
environmental ‘hazard’ is seen as beyond the responsibility of the individual but a
repeated cause of falls.
We’re doing everything we can here in the house, you know so we don’t trip.
We can’t do anymore. Going outside we could trip, but we can’t do anything
about that, because it’s the pavements. (Peggy)
It is implied that if a fall were to occur outside, it wouldn’t be due to an individual or
personal reason, but because the pavement is a hazard that couldn’t be avoided.
Peggy recognises that some actions can be taken to avoid falls, but some risks are
beyond individual control. The reason for the fall seems clear to the person and blame
is apportioned accordingly.
Phyllis also directly refers to pavements, though has never fallen over. Speaking about
if she were to fall;
I don’t think it would be anybody else’s fault, it would be me. Unless you fall
outside or something like that, broken pavements or something like that, which
there’s a lot of them about.
There is inferred a line of accountability for falling on a pavement which is separated
from the statement about personal responsibility for other falls causes.
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The Lucky
In some situations, it is hard to say why some people have the misfortune of
experiencing a fall, and others don’t. For Phyllis, Peggy and Percy who hadn’t
experienced a fall, they referred to themselves as being lucky. Phyllis then went to on
to explain that having not done it, I don’t really know what it feels like. So, having not
had the experience of a fall, she couldn’t explain or understand how a fall would
change, if at all, her approach to preventing falls.
However, Phyllis did indicate an understanding of the potential significance of falling,
mentioning:
The man across here [points], I know he fell so warden got the ambulance to
him. There’s a few in here who fall, just fall in their flats. But lucky I haven’t.
This is the second comment by Phyllis about being lucky not to experience a fall.
Another,
Phyllis – The older you are, the more you may fall. I’ve just been lucky up to
now.
R – How do you mean, you’ve been lucky?
Phyllis – Well, I don’t do anything special if that’s what you mean, I’ve just nay
fallen up to now [laughs, pause] touch wood [touches mantelpiece].
This final statement of not doing anything special may or may not alter depending on if
a fall is experienced and what the consequences are.
Theme Summary: Experience
This theme very much focuses on the Case One perspective of falls and prevention,
based on falls they have experienced or managed to avoid. Humans learn through
experience and alter their behaviour accordingly, depending on a number of factors,
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such as ability, the hazard and risk. Those who have fallen seem more amenable to
engaging with falls prevention, where it is available and/or known about. Where
possible, a reason for falling is preferably sought, perhaps to distract from it being a
self-caused incident which reflects on the person (see ‘Ageing’). For those who haven’t
fallen, fortune is suggested to play a role, and acknowledgement of the value of falls
prevention interventions is lacking. Where falls were experienced and described, the
definition of a fall was different, participant to participant.
4.4.3 Support
The provision and
nature of help to assist
older people to prevent
falls appeared to affect
their ability to engage
with a programme or activity to help avoid falling.
Patronising or Protecting; Pro-action or Reaction
When support is given, it is typically provided with the best of intentions. However this
may not always be how it is received by Case One. The sentiment of trying to do the
best for the person may be taken as demeaning; the individual may feel their
capabilities and personal situation are being overlooked.
R – Do you discuss falls with your family?
Penny – No, no
R – If you needed to, do you feel you could talk to them about falls?
Penny – Well, no…. My daughter’s a fair way away in Newcastle, so I couldn’t
ask her. But she’s one who could really help, because strange as it sounds,
Support
Patronising or Protecting; Proaction or Reaction?
Trust
Limitations and Focus of Formal Support
Figure 7. Illustration of Key Theme
'Support' and Sub-Themes
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because she’s a nurse, or was…… [Mimics daughter’s voice] “Mum, don’t do
this, mum, don’t do that”. And I think, well, what do you think I’ve been doing
these past 80-odd years? [Mimics] “But mum, you’re not getting any younger”
[Laughs]…… It would depend what she told me to do, dear [note of conviction in
voice]. (Penny)
As a nurse, the daughter may or may not have an educated insight into fall and
prevention strategies. But the manner in which Penny remembers other forms of
advice offered to her by her daughter infers that despite perhaps offering it with the
best of intentions, it wasn’t received in that way. The older person would be hard
pushed to take it on board – almost in a push-back, resilient manner, depending as she
says, on what she told me to do. The words ‘told me to’ are very directive, they
eliminate any form of choice and don’t necessarily portray the intentions meant.
When a fall has been experienced, the efforts taken to try and prevent another fall in
response to the situation are a reaction. Anticipatory action is the initiation of trying to
prevent any fall occurring in the first case, i.e. being pro-active to preventing a fall. This
could be before any fall caused by any risk is experienced or following one fall, to try
and prevent a second.
It appears that often it is only in reaction to a fall that any action is taken. Support to
prevent a first fall is not sought nor automatically offered, as conveyed by Pattie.
R - If you wanted to find out about falls prevention, where would you go?
Pattie – I don’t know, I only know you who has talked to me about it [laughs]. I
mean if I were to fall again, I would go to the doctor but that would be after the
fall, not about stopping it …… Mary [the warden], she’s lovely, absolutely lovely.
Really lovely, very helpful….. I mean, if anything ever happens she comes and
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asks you, talks to you. She sits down and has a conversation about it, tries to
help you. I mean Mary could put something on the wall for us to read [about
falls prevention] when we go to the centre, couldn’t she.
There are a number of key points made here. Firstly, Pattie recognises that going to
the doctor after the fall doesn’t assist her in trying to stop the fall in the first place.
Secondly, whilst the warden is warmly acknowledged as being a ‘lovely lovely person’,
the conversation about falling again takes place after the event, and not as a pre-
emptive measure to prevent it happening in the first place. And thirdly is the self-
realisation of a means to share to falls prevention message as a proactive measure
which dawns on Pattie in the moment, having had the opportunity to talk about falls
prevention in the general sense with somebody.
Trust
When individuals interact, especially about something which may be deemed as very
personal, such as falling, they want to be confident that they can trust and rely on the
other person.
R – What is it that makes your residents come and talk to you?
Sally – Trust. It’s trust. When you’ve been here as long as I have. Your residents
come in, you go through everything, they know that you’re here for them. Every
single person in this building know that I’m here for them… They confide in me
about their families, if they’ve any health issues, any problems like that so yeah,
it’s based on trust.
R – So they always tell you when they’ve fallen?
Sally – I’ll never know that [laughs] but probably not. (Sally)
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Sally indicates that trust is not something quickly granted; time taken to build the
relationship and therefore the trust must be considered. Similarly, Susan discusses the
starting point of gaining trust and the process of developing confidence in the
relationship.
I think if we could engage them more …… and they begin to trust the person
that comes in, then their fears [about the future] might be lessened. That yes,
this person is coming in, and yes, my fears were unfounded, that this is about
keeping me in the community and keeping me safe. (Susan)
The notions above of keeping me in the community and keeping me safe link back
around to fears about how the future may change post fall. This may include moving
out of the community, potentially losing independence, but ultimately the knowledge
that falls prevention is about helping the older person to avoid possible harm from
falls.
Limitations and Focus of Formal Support
All the participants could relate to falls either through personal experience or
knowledge of a family member, neighbour or colleague who had been affected. Falls
are a widespread and prevalent issue with varying degrees and types of impact on
individuals, organisations and social communities. Yet no one agency or organisation is
taking the responsibility for tackling falls in a sustained manner.
I mean definitely the NHS did [take a lead] at one time, a few years ago. And
that was really beneficial. And I think we worked as a team then, it was like a
breath of fresh air. It was like the first time I felt we all really engaged – as
social care and NHS working together, integrated…. But now we have this
disjointed approach. We think the GPs will see to it, they think we will.
(Susan)
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Whilst staff may have a professional duty to support older people in their care, this
care has its limitations on two fronts. Firstly, staff can advise older people and support
them in that way as much as they like, but they cannot force the older people to
actually do anything that they are advising. Older people living in their own homes
have the independence and autonomy to take whatever risks of falling, and heed or
ignore any advice or use any intervention at their own choice. For staff to go against
the wishes of the older people would be to breech the jurisdiction of their role.
Describing an older person whose health has noticeably declined over a period of a
month, with an increased risk of falling, Sandra comments;
She’s never let me get in contact with any of her family, even now. If I’ve said,
can I ring your son, you’re not well, she’ll say “no don’t bother, they’re
working”. You’ve obviously got to go by their wishes. So I say, well please, you
tell your son.
Sandra is keen to ensure the most for the older person’s wellbeing but is limited to the
action she can provide towards achieving this with the family.
Secondly, as mentioned in ‘Ageing’, is capability. Case Two speak of the environmental
risk assessment they are tasked to complete for health and safety legislative reasons.
However, beyond that, without the instruction to apply further falls prevention actions
or activities, the time and workload of the staff is focused to other things.
When I go in the flats to do support plans and that and see things, like rugs,
wires, I point it out like “that’s a trip hazard”. I make a point so they are aware
of it. Some of them move ‘em. Some of them choose not to, which it’s their flat,
they can do that you know, it’s up to them. (Sally)
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Theme Summary
Support is usually given with the best of intentions; however how the support is
received can be in contrast to the aim and purpose. This could be due to pride, linking
back to the earlier theme of ‘Ageing’; in particular the capability and image/identity
sub-themes. As such the support may unintentionally be patronising to the recipient.
Both Cases appeared more familiar with reacting to falls, rather than trying to prevent
falling from the outset. This suggests a greater acknowledgement and valuing of falls
prevention post-falls experience, complementing the findings in the earlier
‘Experience’ theme. Case Two participants inclined towards a greater knowledge of
extrinsic falls risk factors and more so than intrinsic. Where known about, preventative
interventions were therefore weighted similarly, with environmental adjustments
being more familiar to Case Two than initiatives or classes aimed to the individual or
personal risk factors. As so few interventions were known about, the opportunity to
get involved was lacking. Where preventative advice or interventions were known and
shared, the autonomy of the older person influenced their uptake.
4.5 Case Synopses
Case One: Older People
A seemingly more personal and raw impression was provided by Case One
participants, possibly due to the effect or potential effect of falls resounding more with
them. They provided a detailed insight to ‘Ageing’, referring to how engaging with falls
prevention impacted upon them. The ‘Experience’ of a fall featured prominently in the
extent to which older people seemed to acknowledge or value prevention: those who
had fallen more were more likely to compared to those who had not. The perspective
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given about ’Support’ inclined towards it being most frequently about reaction to a fall,
and help following the fall, rather pro-active prevention of a first fall.
Case Two: Universal Frontline Staff
Although able to comment on and show passion for falls prevention (and empathy to
those who have fallen), the discussion was more detached from Case Two members.
Views were given on ‘Ageing’ in a supporting but supplementary manner. Insight from
participants who had witnessed and supported older people through the aftermath of
a falls ‘Experience’ provided additional confirmation of the compelling and heightened
need for preventative interventions. Some examples of environmental interventions to
‘Support’ older people to reduce the risk of falls were highlighted; notably other non-
environmental interventions were mostly unknown. Limitations on the permitted
remit and role of Case Two staff were also noted.
4.6 Chapter Summary
In this chapter the findings of the part two empirical data analysis have been
presented. This includes the introducing the Case participants, the descriptive data and
key emergent themes, defined as ‘Ageing’, ‘Experience’, and ‘Support’. These are each
supported by between three and five sub-themes.
Each key theme is interwoven with previous and subsequent themes and sub-themes,
indicating a complex system of factors which have been presented in an
uncomplicated manner. What is especially noted are the individual perspectives of
reasons both supporting and dispelling engagement provided by Case One, versus the
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wider infrastructure of society and system perspective of Case Two to help prevent
falls. The findings are now explored further and discussed in the next chapter.
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CHAPTER 5: DISCUSSION
This qualitative study set out to explore factors affecting stakeholder involvement with
falls prevention. Specifically, the objectives were:
i. Complete a systematic examination of relevant literature regarding adherence
to and motivation for falls prevention.
ii. Explore beliefs and opinions of the stakeholders about what a fall actually is.
iii. Identify barriers and enablers for stakeholders to acknowledge and value falls
prevention.
iv. Explore the opinion of stakeholders on opportunities and challenges to
participate in community approaches to falls prevention.
In the previous chapter the data findings were presented following in-depth data
analysis. This chapter opens with reflections on the process of analysis taken, as this
informs the reasoning for the interpretation of the findings against the literature
evidence. The findings are then broadly discussed in the context of falls prevention
engagement, before the literature, theory and findings are drawn together in the order
of the research objectives1. The limitations of the study are then acknowledged and
their significance discussed. This chapter builds towards the explicit consideration of
the research question in the final chapter.
5.1 Research Reflections
As discussed in Chapter 3, five themes (four derived from the literature review and a
fifth emergent theme from the secondary review of phase one data) formed the basis
1 Objectives are indicated throughout the chapter in italics underneath section headings
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of the semi-structured interview schedule (Appendix 11). This was a starting point for
each interview conversation; an avenue through which to probe for more detailed
thoughts and opinions.
The five theme conceptual framework (Figure 8) remained prominently in mind as data
analysis commenced, framing a deductive approach to analysis. The theory was
presented, hypotheses generated, data collected and an attempt to confirm the
finding fit the theoretical proposition was made.
Certainly some of the data fit the conceptual framework; however this could almost be
expected as the literature evidence speaks volumes around such facts of unavailability
and inaccessibility of interventions, style of communication of the messages and the
provision of education to further knowledge. The spread of themes could have
remained very broad with a degree of support for each, but without adequate depth to
each, and equally not truly utilising the depth of detail the data were providing.
Whilst said that a deductive approach was taken initially, an eye for newly emerging
themes was kept as planned. Opting to pursue the deductive more stringently in the
first instance was not a wasted exercise as it helped to clarify and strengthen the value
of the data. As such, analysis of the data recommenced but with a tactical difference –
Intervention
Communication
Knowledge and Education
[Support]
Attitudes and Beliefs
Figure 8. Conceptual Framework Following Secondary Review of Phase One Data
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be inductive and seek out the conceptual theory from the data, themes and patterns
emerging.
5.2 Interpreting the Findings beside Falls Prevention Engagement
Ahead of exploring the research objectives in detail, the following section provides
further insight to the understanding and alignment of the findings to the broad
concept of falls prevention and engagement.
5.2.1 ‘Ageing’ and Falls Prevention Engagement
‘Ageing’ is a multifaceted theme, presented as the first and dominant within the
findings. The classification by both Cases of ‘Younger Old’ and ‘Older old’ people
implies certain differences between the two, not least the relevance and association of
falls prevention. Inclusion into one group or another may be as prescriptive as number
of years, but independence, mobility and lifestyle also appear to be important factors.
If you are an ‘Older Old’ person, due to physical and psychological abilities, the
appropriateness of falls prevention is considered higher. When describing what a fall is
though, ‘Ageing’ characteristics did not feature as part of the justification to why a fall
was defined in a certain way.
‘Acceptance’ of ageing may influence the choices the person makes about how to
continue to live their lives. This may include adapting their lives to address areas where
they are perhaps a little less capable and incorporate strategies to cope with and best
approach situations. Falls prevention is an example of this, with older people being at
increased risk of falling but there being a number of interventions available to reduce
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the risks, which often have other beneficial effects for other areas of physical and
social health and wellbeing.
‘Acceptance’ is easy to say, but harder to undertake; and harder still to be truly
accepting, especially where a decline in ‘Capability’ is noticeable. Acceptance can
enable acknowledgement of limitations in a range of activities and lifestyle choices. If
hazards are identified, then action can be taken to reduce or mitigate associated risks.
Correspondingly for falls prevention: if ageing is accepted and a higher risk to falling
acknowledged then falls prevention interventions may be valued, helping to identify
hazards and potentially reduce the risk of falling.
The investment of time in a falls prevention programme or suffering a fall may impact
on the ‘Image and Identity’ of the faller, young or old, and of either Case. However in
Case One, it appears to signify a decline in capability of the older person to both
themselves and the rest of society. This may be over a short or longer time frame,
depending on the circumstances and consequences of the fall. That is, the image of an
active, mobile and independent individual who is challenged and changed
detrimentally. This may be due to the apparent negative connotation of what both
falling but also taking action to prevent falls suggests about the individual.
Acknowledgement and engagement with falls prevention, a least publically, is
therefore lacking. Furthermore, it could be suggested that due to negative
stereotyping, even if community falls prevention interventions were more widely
available and publicised, their uptake would potentially also be lacking.
The positive association of being proactive to prevent falls in an effort to keep well
seems vastly overlooked, certainly by Case One. It is suggested in the findings that this
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may in part be due to a ‘Fear’ of what a fall symbolises about the person; vulnerability
and an uncertain future of dependence on others. A fear of falling was also mooted by
some who had experienced a fall, and as such any preventative advice was welcomed.
However there seems to be a crux where the causes of fear appear head to head and
in conflict with one another. The fear of falling and wanting to do all to prevent the fall,
set against frightening thoughts of what might happen, the ‘what if’ and not wanting
to dwell on the negative prospect.
Ageing can ultimately affect every area of life; changing social activities, lifestyle
choices and independence through its effect on physical and mental health. A person’s
individual ‘Attitudes and Beliefs’ can impact on their choices and behaviours, and
inform their decision about how to engage with falls prevention. The dominance of the
‘Ageing’ theme is proposed as falls are evidenced and anecdotally recited as a
significant issue to the older generation, and Ageing is a process which affect everyone
and in many different ways.
5.2.2 ‘Experience’ and Falls Prevention
The theme ‘Experience’ is led by Case One data, supported notionally by Case Two.
Those who have ‘Fallen’ suggest actions they have since taken to try and prevent
falling again. It could be said that, having fallen, they acknowledge their personal risk
of falling more, and hence place value into what falls prevention can offer. The method
of prevention is personal to the individual, including them ‘Taking Care’ more. Beyond
this and addressing environmental risk factors, participants knew little about falls
prevention interventions to accommodate this. Associated with this, opportunity to
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participate in local community falls prevention was minimal. If interventions are not
available or known about, it reasons that engagement with them will be negligible.
One of the biggest indicators of risk of falling is, poignantly, a history of experiencing a
fall; with each fall, the risk increases if suffering a more serious injury.
Exploring the connectedness of the themes, a high risk of falling could be due to an
illness or condition which impacts on ability, or simply through natural ‘Ageing’
processes. ‘Ageing’ can also notably reduce the ‘Capability’ to react to hazards,
thereby for example, increasing the risk of a fall occurring or the ability to manage the
fall. Where Case One highlighted whose engagement in falls prevention through using
a frame or a walking stick to provide extra support, a link between ‘Capability’ and
‘Acceptance’, perhaps even just acquiescence of ‘Ageing’ and situation is suggested.
Apportioning ‘Blame’ to the cause of a fall, or seeking a ‘Reason’ to why the fall
occurred seemed important to some. This could be to divert the attention away from
the older person, thus deflecting or postponing the need for the older person to
acknowledge and engage in falls prevention. For ‘The Lucky’ who hadn’t experienced a
fall and those who saw falling as fate, falls prevention was only casually acknowledged.
As such, it is unlikely that it is valued. Without appreciating the potential benefits, it is
feasible to suggest that community falls prevention interventions, where available,
may not be attended.
5.2.3 ‘Support’ and Falls Prevention
‘Support’ can take a variety of forms including verbal prompts, hints and tips to
prevent falls, through to physical assistance towards participating in a falls prevention
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activity. Support can also be provided by a range of people, such as family, paid carers,
or professional statutory personnel. This theme is primarily upheld by Case Two data,
with additional Case One perspectives.
The intention of ‘Support’ as a means of ‘Protecting’ those from falls is taken by some
participants in this study to be ‘Patronising’. This may be so if the ‘Capability’ of the
individual is thought to be challenged. To be receptive of support to help prevent falls,
the older person’s acceptance, or at least acknowledgement of their own personal
situation and risk of falling must be recognised. The communication style and
interpersonal skill of the individual is suggested as being an important consideration to
achieve the best outcomes for the older person and supporting individual alike, as
indicated in the ‘Communication’ element of the proposed conceptual framework
(Figure 8.). In addition, the sometimes directive ‘Support’ offered by Case Two, though
perhaps not quite be patronising, doesn’t fit with the image of a protective, supportive
and empathetic individual. Whilst the support/instruction may be given with the best
of intentions, it therefore may not be received or acted upon, especially if there is little
‘Trust’ between the older person and staff member.
A ‘Focus’ held by Case Two participants providing formal support was to address
environmental falls risks. Though beneficial to be working towards reducing these falls
risks, both Cases appeared to lack awareness of intrinsic risk factors. The knowledge
and education about the intrinsic risks and preventative intervention seemed wholly
unknown. This links and corroborates findings regarding the inconsistency and
hesitancy with which participants spoke about falls prevention contacts and services.
Unlike for example, fire prevention issues where a single organisation is renowned as
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the point of contact, the same cannot be said for falls prevention. However it is only
when a fall occurs, and especially when an injury results, the NHS are involved. For the
primary prevention of falls, that is prevention of a first fall occurring as opposed to
prevention of subsequent falls, the NHS are not consistently approached. Nor do they
presently have the imperative, capacity or resources to regularly and equitably provide
the interventions (Oliver, 2009).
Some Case Two participants discussed the ‘Limitations’ of their role in formal support.
They could advise older people on falls risks and how they might best try to prevent
falls but only with the consent of the older person could any action actually be taken.
This is good practice for the older people to remain independent and autonomous in
their lifestyle choices. The use of communication skill and encouragement from a
‘Trusting’ relationship may positively influence the ultimate decision taken by the older
person to prevent falls.
The chapter will now address and discuss each research objective in turn.
5.3 Mapping the findings to relevant literature evidence
Objective i. Complete a systematic examination of relevant literature regarding
adherence to and motivation for falls prevention.
It is suggested that the emergent findings from the phase two empirical data provide a
deeper insight into of the conceptual categories identified in the literature review;
particularly ‘Attitudes and Beliefs’ and ‘Knowledge and Education’. The emergent
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Age
Experience
Support
Intervention
Support
Attitudes and Beliefs
Communication
Knowledge and Education
category from the secondary review of phase one data is also reinforced in the phase
two findings in the theme ‘Support’. This is illustrated in Figure 9.
At the outset of the study, it wasn’t the intention to focus on the ‘Support’ and
‘Attitudes and Beliefs’ themes portrayed in the conceptual framework. The themes of
‘Knowledge and Education’, ‘Communication’ and ‘Interventions’ are present in the
findings but to a much lesser extent. Their presence is acknowledged indirectly,
through the manner in which they are not known about, addressed or considered by
participants. For example, with ‘Interventions’, the lack of familiarity and awareness
with falls prevention interventions highlights an issue in itself; that interventions are
not known about, irrespective of whether they are available or accessible to
stakeholders. This is informed by and impacts on the ’Knowledge and Education’; what
is understood by participants about falls prevention is not comprehensive and there
are few learning opportunities available. Furthermore, without experience of
interventions, the ’Communication’ style, pitch, tone and materials are not known to
be recognised for being appropriate, poor or otherwise.
Primary Findings
Figure 9. Synthesis of Conceptual Framework with the Primary Findings
Conceptual Framework
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It must also be acknowledged that the research interviews may not have probed deep
enough to gain an absolute picture of the Case perceptions with regard to all themes.
Whilst in-depth interviews were performed, follow up conversations with participants
were not conducted. These may have been useful to gain further data to solidify and
consolidate the interpretation further.
5.4 Discovering the subjectivity of definition
Objective ii. Explore beliefs and opinions of the stakeholders about what a fall
actually is.
The biomedical stance on Successful Ageing suggests that life expectancy is optimised
by the absence of disease and disability, both mentally and physically and not
influenced by extrinsic factors (Rowe & Kahn, 1997; Bowling & Dieppe, 2005). A fall in
itself is neither a disease nor disability, but can be the precursor to injury or illness.
To determine what a fall is, consideration is given to why the fall occurred, where the
fall happened, and who, if anyone, witnessed the fall. These factors all contribute to
the distinction as to whether the individual determines whether they did actually fall,
or indeed, the incident was some other mishap. Offering any number of reasons for
falling, or calling the ‘fall’ by another phrase avoids the negative connotation and also
distracts from what might be the failing of the health of the older person. The use of
rationale to explain the fall is intriguing as Rowe and Kahn (1997) suggest that high
cognitive functioning indicates Successful Ageing. However, to use reason to mask a
potentially low physical functioning - a weakness or susceptibility to falling - starkly
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contrasts the ideal of Successful Ageing. Not admitting when a fall has occurred then
becomes an antecedent to the challenge of engaging stakeholders in falls prevention.
The subjectivity of defining a fall adds to the complexity of engaging stakeholders in
falls prevention. If older people understand a fall differently, the challenge of
developing a falls prevention intervention to complement the variety of falls
definitions is extremely demanding. To then provide these falls prevention
interventions is unachievable in today’s healthcare economy. These challenges are
referred to as issues of availability and accessibility of the theme ‘Intervention’ as
highlighted in the literature (Whitehead et al., 2006; Chou et al., 2006; Fortinsky et al.,
2004).
5.5 A Paradox of Theory and Findings: Prevention versus Pride?
Objective iii. Identify barriers and enablers for stakeholders to acknowledge and
value falls prevention.
Older people have autonomy to act to prevent falls as best they see fit, within the
boundaries of resources and policy direction provided by society. This appears feasible.
However there is a distinct paradox between what appears as feasible and the
narrative portrayed in the research findings. The data present a realisation of the
potential consequences of falling, but a lack of application to preventative action. This
is due to a majority of ‘Attitudes and Beliefs’ factors which are pertinent to the
individual. The unlikeliness of wanting to exacerbate health decline has been stated, as
potentially would be the case should a fall occur. Falls may lead to post-fall syndrome,
which includes increased dependence, loss of autonomy, confusion, immobilization
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and depression (WHO, 2012, p. 20). Falls prevention is reiterated as being part of the
process of successful ageing, and yet it does not appear widely or routinely engaged
with.
The findings from this research study uncover a strong emphasis on the subjective
influences of the ‘Attitudes and Beliefs’ surrounding ‘Ageing’ and ‘Experience’ for both
Cases to acknowledge and value falls prevention. These themes recognise the
individual perspectives about ageing and falls as a factor in the extent of engagement
with preventative interventions, combined with the focus of ‘Support’ available.
The Successful Ageing theory suggests that engagement with falls prevention as a
means to prolong a healthier life should be automatic. Yet the reality interpreted from
the data suggests there are subjective factors which influence a person’s likelihood to
engaging with falls prevention. A précis of these is provided in Table 9. Of note is the
presence of some enablers as the reverse of the barrier presented. For example, lack
of experience of a fall may be a barrier to engagement but conversely, to have
experienced a fall is an enabler. Similarly fear of falling is an engaging factor, yet fear of
the association with falls prevention is a threat to participation. Irrespective of this,
reasoning assumes that before a subject can be valued, it must first be acknowledged.
If a subject is not known about or recognised, then it’s worth cannot be appreciated.
This section therefore proceeds as such, splitting objective iii into two. Firstly, the
barriers and enablers into expressly acknowledgement of falls prevention are explored
(section 5.5.1). This is followed by the barriers and enablers to specifically valuing falls
prevention (section 5.5.2).
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Barriers Enablers
To Acknowledge
Falls Prevention
- Self-concept of age and ability:
falls prevention not applicable
- Fear of what this means next,
the future: denial of situation,
ignorance of risks
- Support limited to extrinsic risk
factors: intrinsic issues are
overlooked
- Boundaries of formal support:
only so much can be done,
beyond the role/ remit
- Appreciation and acceptance
of age and ability: comfort in
self-concept
- Fear of falling, fear of the
future beyond a fall: to want to
find out more
- Support to recognise what can
be achieved, what is available
- Experience of a fall:
comprehending that something
may have prevented it, or
reduced the likelihood
To Value
Falls Prevention
- Lack of acknowledgement of
falls prevention: if not
acknowledged, can it be valued
- Reaction: a fall must be
experienced before falls
prevention is valued
- Experience of a fall: knowing
what happening, the
consequence and trying to avoid
a repeat
- Support to appreciate the
potential benefits: the links to
and positive impacts on other
areas of health and wellbeing
Table 9. Indication of the Beliefs and Attitudes to the Barriers and Enablers to
Acknowledge and Value Falls Prevention
5.5.1 Acknowledging Falls Prevention
Attitudes and beliefs are rooted in the psychological and sociological understandings
an individual interprets based on their personal traits and life experience. They bring
the unique subjectivity to whether a person chooses to engage with falls prevention or
not.
Bowling and Dieppe (2005) indicate that the psychosocial elements of Successful
Ageing include social integration and reciprocal participation in society. The labelling of
older people in to ‘younger-old’ and ‘older-old’ sub-groups is differentiated by both
study Case groups; a distinction made by the public and professionals alike. It affirms
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the crude statutory years of age which govern when a person is officially identified as a
pensioner though is a more discerning way of categorising older people (Stuart-
Hamilton, 2012). The impact of this could instil a very negative connotation of frailty
which supersedes the individual’s assumed value to and worth in society. This may
lead to a detrimental segmentation of the sub-groups which conflicts with the ideal of
Successful Ageing, and with fallers being attributed to the ‘older-old’ sub-group,
despite actual physical age, emphasises a disliked association. As such, engagement
with interventions is likely to lessen, rather than be promoted.
Both Simpson et al. (2003) and Yardley et al. (2006) found that whilst older people
found elements of falls prevention information useful, they didn’t feel it was relevant
to themselves. The true cause for this dismissal may differ for each individual older
person, however the inherent categorisation of falls as something that happens to the
‘older-old’ sub-group could be a very significant reason and inhibit engagement with
falls prevention.
The idea of self-concept encompasses how, or indeed if, an individual has accepted
ageing and the impact it has had on their capability (Gana, 2012). [Gana is the author
of the chapter] Furthermore it influences their perceived image of themselves and the
identity they portray to the rest of the world. If the portrayal is deemed negatively,
less engagement is likely. Fortinsky et al. (2004) indicate that specifically pride and
willingness are obstacles to a patient’s uptake of a direct falls prevention intervention.
Therefore issues of sacrifice, behaviour changes and matters of vanity may affect an
individual’s choice of and compliance with falls prevention interventions.
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Stroebe (2011) questions why individuals are resistant to encouragement, despite
action being in their own self-interest. The quandary feels very applicable to falls
prevention. Participation in an intervention of the individual’s own volition would offer
the greatest benefit in return (Simpson et al., 2003) though engagement on any level
appears lacking. As Dickinson et al. (2011, p. ) point out; individuals must ‘find the time
to participate’. If the benefit of the falls prevention initiative is not recognised then it
will not be prioritised. Again, if something is not first acknowledged, then reason
dictates that there will be little value put on its worth, and little attempt to engage.
Acceptance of ageing and the associated changes in physical and psychological
capability can affect the approach taken to falls prevention. Each person’s passage
through ageing is heterogeneous, travelled most usually along a meandering path of
time and events. It is a different experience for different people (Moody & Sasser,
2012). Individual perceptions of ageing are fusions of experience and self- concept on a
continuum, influenced by the company kept and social context lived. The older person
will therefore see themselves through their own internal lens but equally will hold an
external identity to their family, friends, and peers in general. Successful Ageing in the
psychosocial sense, builds on the ability to use past experience to cope with the
present situation. This psychosocial strength then impacts on the ability to adjust to
physical changes in older age. When a person of any age falls a sense of
embarrassment may be felt (Chou et al., 2006). It could be said that the stronger the
individual is psychologically and the more comfortable with their age and ability, the
more likely they are to acknowledge their risk to and history of falling. Indeed,
character traits of stubbornness and a wish for ignorance in the face of uncertainty
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may prove to outweigh the ideal for Successful Ageing and lead to no discussion about
falls or falls prevention. Human nature works in contrary fashion to the theory offered.
The model presented by Rowe and Kahn (1997) explains the rationale for preventative
and proactive action to be taken to aid the desire of ageing successfully. The findings
suggest that this is an ideal, because there is an additional trigger which intervenes
when illness or injury is involved; fear, and the stark reminder of the individual’s
morbidity and mortality (Settersen, 2006). [Settersen is the chapter author] Fear is a
reaction brought on by a sense of threat, danger or a continuing or worsening
unacceptable situation. Fear may push people into limiting their actions or make other
attempts to prevent falls. Fear may also have the reverse effect though: rather than
act as a ‘pull’ towards preventative action, the inclination is to ‘push’ away and deny
the situation that is faced. Thus, acknowledgement of falls as an issue, and falls
prevention as a good and beneficial intervention are repelled. It may be ignorance or
purely denial, but when confronted with a fear-provoking future individuals choose not
to recognise the need for falls prevention intervention.
Overall, a lack of knowledge about falls prevention interventions was noted. This was a
theme identified in the literature; ‘Knowledge and Education’. Where examples of
initiatives were discussed, the focus was on extrinsic risks and preventative action. This
was most apparent from the universal staff who appeared attentive to the risk factors
related to statutory Health and Safety Executive legislation. A wider understanding and
appreciation of additional risk factors and preventative interventions was not present.
This is in-line with the findings discussed in the literature review (Fortinsky et al., 2004;
Dickinson et al., 2011; Chou et al., 2006; Yardley et al., 2006).
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In addition, formal support staff, as provided by paid carers and domiciliary staff and
volunteers to charitable organisations, are limited by the boundaries of their job roles.
Indeed they are in position to care for and support older people, but the scope and
depth of their work remit is prescribed by their employers. Ensuring the health and
safety of people in their care, especially in communal areas of residential building is a
statutory requirement and links very much to extrinsic falls risks factors. However
intrinsic factors are not covered in legislation, and as such, staff education is not
compulsory. This is similarly reported by Oliver (2009). From a support perspective,
this is very limiting. If staff are not aware of the range of falls risks and interventions
available then there is little possibility of these being communicated to the older
people they are working with.
Rowe and Kahn (1997) proffer the use of external support and relations to enhance
Successful Ageing. With regards to falls prevention an older person may seek advice
from a channel of support, however if they are not knowledgeable about falls or
prevention then this is a challenge. The older person may seek out the advice from
another source, or may not bother to, in which case the opportunity is missed.
A limitation of Rowe and Kahn’s (1997) Successful Ageing model is the focus on the
individual to seek support as a unilateral ‘pull’ as part of the third facet of the model,
active engagement with life. The model does not provide for the ‘push’ of support to
the older person, nor the exchange of requests and offers of support, be it
information, physical assistance, company, guidance or advice. To satisfy the
requirements of Successful Ageing and to align falls prevention with this, it is
suggested that support and social engagement are diffused to allow reciprocal
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exchange of the individual seeking, and surrounding peers, informal and formal carers
to offer in the collective interest of the older person.
5.5.2 Valuing Falls Prevention
It can be problematic convincing people that they may be susceptible to health risks
(Stroebe, 2011). As discussed, Case One especially do not want to be thought of as
vulnerable, and even if they recognise a weakness, taking action and changing
behaviour accordingly is another step. Each individual is guided by their own
independent experience, situation and ambition (Forshaw, 2002). This includes the
decision made about the value and benefit of taking the preventative action.
Furthermore, this includes the judgement made about the cause of a fall, based on
experience and acceptance of situation may influence what the cause of the fall is
attributed to: a ‘reason’ or simply ‘fate’.
Correspondingly, Yardley et al. (2006) found the view that falling is inevitable and
cannot be prevented. Furthermore, the opinion that falls prevention is ‘common
sense’ prevailed (Yardley et al., 2006, p. 513), whilst Simpson et al. (2004, p. 158)
highlighted ‘taking care’ as a strategy to prevent risks for older people and universal
staff alike. Whitehead et al. (2006, p. 541) reported that participants felt that they
were ‘safe enough’. These sentiments are all maintained in this study, as found in
‘Experience: Taking Care – Taking Risks’. The sense is taken that attendance at a
specific falls prevention intervention is deemed unnecessary. Little or no value is put
on the benefit the intervention may give to the older person, either to prevent falls or
to enhance another aspect of life, such as social wellbeing.
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Poignantly, a sense of ‘in hindsight’ is accentuated after the event, i.e. after a fall has
taken place, when individuals may acknowledge the limitations of their physical and
psychological capabilities and propose how they might have done things differently or
taken preventative action. Ironically at this point, in some cases, is too late to reverse
the impact of the fall, other than to try and take the learning forward towards helping
prevent another.
Considering the ‘Support’ theme in reference to valuing falls prevention, the
knowledge and education of staff and older people has been discussed. Without or
with little understanding or opportunities to learn about falls prevention, the support
offered, whilst meaningful, isn’t specific nor attuned to falls, falls risks and
interventions available. In addition, the pitch and tone used to communicate the
importance of falls prevention to older people may not be appropriate. Conveying the
falls prevention information with integrity and in a fitting manner; respecting of its
value to be given to the recipient may influence the decision to partake (Dickinson et
al., 2011). If an older person hears the same message about the benefits from a
number of different sources, they may start to take heed of the advice.
It could be though that falls are deemed too great a challenge to tackle; universal staff
have too many competing priorities to address with the older people they serve, and
little time to fulfil their duties in. Falls prevention gets pushed from the forefront of
actions (Chou et al., 2006) with staff perhaps thinking that another staff member, from
either their profession or another, will pick up and deal with the risk and the matters
presenting. There may be an inclination to deal with the fall issue only after the fact
and in reaction, not preventatively. This challenge is about the system valuing the
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benefit that falls prevention intervention can bring to the older generations health and
well-being, and branches out to impact on the dominance of resources invested in
reacting to health care issues, versus those available for preventative action.
As with many of the findings in this study, one theme may be examined in isolation,
however to gain the truest perspective on the challenges, a rounded view should be
taken. Each theme is influenced by the prior theme, and in turn impacts on the
subsequent. For example and as stated earlier, a key factor in stakeholders valuing falls
prevention is their acknowledgement of their age, circumstance and risk to falling. For
universal staff and older people alike, knowing about falls, their risk factors and
preventative action is a pre-requisite for appreciating and participating to gain their
true value and benefit to the person.
5.6 What can I sign up for? Where do I find out more information?
Objective iv. Explore the opinion of stakeholders on opportunities and
challenges to participate in community approaches to falls prevention.
The findings of this research study indicate a dearth of awareness by participants of
both Cases of any community falls prevention approaches. By its very nature this is a
significant challenge; if an intervention is not known about, the opportunity to
participate equally unknown and not fulfilled (Yardley el at., 2006).
If universal staff are not aware of the scale of falls within their communities (Chou et
al., 2006; Fortinsky et al., 2004) then the likelihood of the provision of falls prevention
interventions to communities is small. This echoes back to the acknowledgement of
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falls and falls prevention but from a different viewpoint: that of the staff and
potentially social infrastructure. Staff could be provided with a directive to create falls
prevention interventions which are available and accessible to communities. At
present, and as Oliver (2009) recognises, there is no set instruction to deliver this, only
best practice guidance which suggests a range of falls prevention interventions
however these are constrained by fiscal resources and in completion with a host of
absolute deliverables.
Where falls prevention is addressed in communities, this study has intimated that the
boundaries of professional support restrict the focus of prevention for falls. Attention
is most directly related to the legislated health and safety actions, encompassing
environmental hazard reduction and risk prevention. Providing or facilitating more
holistic community falls prevention appears mostly out of their supporting remit. It is
hoped that moral inclination and professional acuity would direct universal and
community staff to at least comment, if not act on other risks identified. However the
parameters of influence of the staff and ethics of older peoples’ personal choice must
be recognised throughout. As such, the issue of engagement is referred back to as
being one of personal choice for older people, and directed by organisational policy for
frontline staff.
5.7 Limitations
Supplementary to limitations noted throughout this study report are additional aspects
which may be critiqued for their significance. That is not to comment on the quality of
this research in isolation: there are factors to be reflected on and considered in all
research projects.
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Using the design principles of an instrumental case study, an examination of a
perspective on a subject to gain deep insight into the subject itself, the sample size is
small. Case study design does not necessarily require a large sample; according to
Stake (1995), the depth of perspective of the Case is important. However others
suggest that findings should hold some generalisability and the potential for wider
significance (Mason, 2002).
Examining the sample further, a purposive strategy was taken to recruit participants.
Although having been contacted by letter and telephone for this phase two study and
therefore reminded of the subject of the study, it must also be acknowledged that
each participant visually recalled the researcher at interview as someone associated
with falls and falls prevention. This was due to the participant-observer and role of the
researcher in the evaluation of the phase one study of ‘STEADY on!’. This may create
both benefit and bias to the study. The benefit is based upon the previous meeting
between the researcher and participant as a positive trust building encounter which
would enable a more frank interview to take place. The bias could potentially be two-
fold. Firstly, as described above, the researcher as a reminder which may have
stimulated or influenced the responses given by participants (Bowling, 2009).
Secondly, as previously attendees of a falls prevention intervention (‘STEADY on!’,
Appendix 1), it is reasonable to assume that the stakeholders could have more
knowledge and insight into falls prevention compared to those who have not received
any falls prevention education or previously engaged in an intervention.
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Related to this point however, when types of falls prevention interventions were
considered during the interview conversations, the majority of the participants’
understanding was limited to that of the one type they had experienced (‘STEADY
on!’). Therefore, any further discussion about type, access, availability,
appropriateness of falls interventions was restricted in the first instance, and then
influenced by the information provided by the researcher in response to participants’
questions.
When presenting the findings in context, the application of a single exemplar model,
whilst sufficient to fulfil the requirements of this academic award, is constraining on
the overall direction of discussion and conclusions of this thesis. Further cross
examination and application of appropriate frameworks would enrich the quality of
the discussion and augment the value of the study in a holistic sense.
5.8 Chapter Summary
This chapter has explored and interpreted the findings of this study against the
research objectives set, using the literature evidence and Successful Ageing theory to
inform the discussion.
A systematic review process identified key literature relating to older people and
frontline staff perspectives on falls prevention. Adherence to falls prevention initiatives
may be firstly based on their being an intervention available and accessible. Without
information and interventions, people cannot know they exist or further their
knowledge and education on falls risks and prevention strategies. The manner in which
falls are communicated about should be suitable and appropriate to the audience,
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enticing them to adhere and motivating them to participate. This is particularly
relevant due to the range of attitudes and beliefs about falls and falls prevention that
are held by both older people and universal frontline staff. Successful Ageing theory
was introduced as an idyllic model for approaching the journey to older age.
No common agreement about what constitutes a fall was indicated by the participants.
The variation was noted both across and within each Case, with many describing
caveats based on personal experience to justify their opinion of what a fall is. This was
dependent on the circumstances leading up to the ‘fall’, where or who blame for the
fall might be apportioned, who was around to witness the fall, and whether the
individual could get themselves up after the fall. The opinions of what a fall is are
therefore personal to the individual. Although it may be suggested that a fall is simply
when a person unintentionally ends up on the ground, the context preceding and
outcome following the ‘fall’ alter this view.
Inadvertently, this objective is the most fulfilled following the approach taken to the
research question. Synthesis of the literature accentuated a more system based focus
of reasons for stakeholders to have the opportunity to be aware and furthermore
realise the value of falls prevention. However the findings from this research study
uncovered a stronger emphasis on patient specific factors to address if and when
stakeholders acknowledge and value falls prevention.
The barriers stakeholders face in acknowledging falls prevention are related to self-
perception of their age, ability, fear and the focus of support they receive. Falls are
generally thought of as synonymous with being ‘old’; an image and realisation that
most individuals do not want to portray or admit. It could then be argued that if
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people are not prepared to acknowledge falls prevention, then this in itself is a barrier
to them appreciating the value of it. A further challenge for stakeholders to appreciate
the value of falls prevention is that generally it is only when individuals have
themselves experienced a fall that they value and wish to engage with falls prevention.
This has a certain irony, for although the outcome of valuing falls prevention is
desirable, the cause for this effect, i.e. the experience of a fall, is not.
The focus of support received presently appears to be weighted to the environmental
aspects of falls prevention. As such the intrinsic elements relating to the individual’s
personal state of health and wellbeing are overlooked and therefore rarely
acknowledged.
Enablers to acknowledging falls prevention incorporate some of the reverse of the
conclusions for the barriers. Fear of falling may increase the likelihood of an individual
acknowledging of falls prevention; the experience of falling may alert individuals to
thinking about what could be done to prevent falls. Recognition of what precautions
could be taken and the interventions may be available may be highlighted or sought.
Accordingly, this may heighten the willingness to value and engage with initiatives to
prevent falls. With the right support and caring intention balanced with appreciation of
the individuality and independence of the older person, falls prevention may be
acknowledged for what it has to offer. Consequently, it may be valued for the benefits
it may bring in preventing falls and the parallel impact on other areas of health and
wellbeing.
Unfortunately, the findings of this research study indicate a dearth of awareness by
participants of both Cases of any community falls prevention approaches. By its very
117
nature this is a significant challenge; if an intervention is not known about, the
opportunity to participate is equally unknown and not fulfilled.
The boundaries of professional support suggest that the focus of prevention for falls is
most directly related to the legislated attention to health and safety, encompassing
environmental hazard reduction and risk prevention. Providing or facilitating more
holistic community falls prevention appears mostly out of their supporting remit.
The final chapter will now draw the study conclusions together and offer
recommendations for their use.
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CHAPTER 6: CONCLUSION AND
RECOMMENDATIONS
In order to answer the research question, “What are the challenges to engaging
stakeholders in falls prevention?” a qualitative research study was undertaken. In the
previous chapters, literature evidence relevant to this study has been presented, the
methodology and methods used to approach the study have been defined, the findings
shared and most latterly the implications of the data discussed. This final chapter will
summarise the conclusions drawn from the study and propose recommendations for
the application of the research and suggestions for further research.
6.1 Responding to the Research Question
What are the challenges to engaging stakeholders in falls prevention?”
A fall is commonly referred to as an accident – an unforeseen or unplanned event or
incident that occurs without intention or purpose. People don’t set out to fall on
purpose and yet there appears an obscurity surrounding the cause of falls and what
can be done to try and prevent them.
Engaging stakeholders in preventing falls would seem a sensible option, given the
potential for injury and associated dependencies that may occur. The Successful
Ageing ideal depicts a motivation for an older age of continued independence, free
from disease and social contentment. Gaining engagement in falls prevention would
therefore seem straightforward: stakeholders should want to get involved to minimise
their falls risk potential and thus promote the likelihood of realising their aim.
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However there is a certain irony that develops between what is the theorised
approach to Successful Ageing, and what actually happens when falls prevention is
promoted, as demonstrated in the present study. There are challenges to both
individuals and society surrounding the interpretation of falling: what a fall means;
how it may be prevented; why falls prevention should be engaged with. Attitudes and
beliefs about both falls and ageing are extremely complex. As separate challenges
(‘falls’ and ‘ageing’) and in combination (‘falls and ageing’), these appear as the biggest
challenges to engaging stakeholders in falls prevention. How individuals and society
perceive falling and ageing are misaligned to the assumed aim of ageing successfully,
with a resulting cyclical effect. Put simply, (1) people don’t want to age, or be
associated with ageing; therefore they shy away from anything associated to ‘ageing’.
(2) Falls are related to ageing therefore falls prevention is avoided. (3) This may result
in an increased likelihood of a fall (dependant on lifestyle and co-morbidities). (4) As
such, when if/when a fall occurs, the outcome is the opposite of the original intention
(1). Therefore, the personal and societal approach to Ageing is identified as one of the
challenges in truly engaging stakeholder in falls prevention.
Ironically, experience of a fall is suggested from the data in this study as an enabler to
engagement. Using the simple cycle described above, when (4) occurs, allowing for the
physical circumstances of the individual, the inclination and motivation to participate
in falls prevention is increased. The realisation of the potential consequences of a fall
drives the individual to get involved to try and reduce the likelihood of a further fall. In
this sense, experience fits with the Successful Ageing model as it is the individual who
seeks the support for their own health and wellbeing.
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However support to engage in falls prevention is fragmented and inconsistent: it must
be available when an individual pursues it whilst also exist to seek out those who may
need it. At this point the wider factors of falls prevention being known about;
intervention being available and accessible and the manner in which they are
communicated to older people become relevant. The precedence given to falls
prevention by organisations and society impacts on the priority regarding support for
falls prevention. If the significance of support on falls prevention was promoted, then
engagement may well be improved. The lack of profile, the lack of support for falls
prevention is consequently identified as a barrier to its engagement.
True appreciation of the challenges in falls prevention engagement is important to
facilitate a greater understanding of what effective practices in stakeholder
engagement are. That said, the conclusions stated here are based on the finding of this
study which was not without its limitations; most notably methodological factors such
as sampling strategy, sample size and participant demographic. These factors have
been presented and discussed in Chapter 3. However, these factors satisfy the
requirements for Case Study methodology, their impact on generalisability (see section
5.7) must be again emphasised and considered when appraising the conclusions.
A number of key recommendations will now be outlined which may assist in the future
delivery of falls prevention, which again must be regarded and assessed against the
same limitations as noted for the conclusions.
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6.2 Recommendations
The findings of this study highlight the need to address the current format of falls
prevention delivery and for alternative approaches to improve engagement to be
tested. The following recommendations are proposed for consideration and have
application in three capacities.
6.2.1 Policy
- Development of a national strategy for falls prevention, which sets standards for falls
prevention knowledge and incorporation into practice by organisations who work
principally with older people.
- A single organisation to take the lead on responsibility for falls prevention with multi-
stakeholder engagement, rather than a devolved, assumed and ad hoc approach. For
example, at present the Health and Safety Executive legislate regarding environmental
accident prevention in the workplace and public/civic areas. This existing remit could
be examined as an opportunity to include broader, intrinsic risk elements in their
portfolio. Other national public service organisations, such as the NHS or adult social
care providers could similarly be identified as well situated to undertake this role.
- Organisations could think beyond their statutory duties and consider the holistic care
of their wards, based on evidence (falls rates) and feedback (soft intelligence) of what
affects their residents (falls).
- To oblige all organisations delivering a health, social or wellbeing service to older
people to educate their staff to a minimal standard in falls prevention, to include
intrinsic and extrinsic risk factors, local interventions available and source(s) of further
information.
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6.2.2 Education
- Emotional elements of ageing included in falls prevention training.
- Falls prevention included holistically in the curriculum of health and social care
programmes, particularly Successful Ageing, public health and care of the elderly
education.
- Curricula guided by agreed minimum standards for knowledge and practice.
6.2.3 Practice
- The development of comprehensive falls prevention interventions which incorporate
empathy to individual and society attitudes and beliefs on ageing and falls, including
self-image and recognition of circumstance and social situation.
- An increase in the availability of falls prevention interventions.
6.3 Suggestions for Future Research
It is recommended that additional qualitative research be carried out in this research
field. In particular, suggestions include:
- Further detailed investigation into the relationship between ‘Attitudes and Beliefs’
and falls prevention, to gain more insight to the barriers to engagement with falls
prevention these factors bring.
- A deeper exploration into the nature of ‘Support’ and how it impacts on engagement
and facilitation of falls prevention, by the formality of provision (paid or voluntary, by
organisation or family). As a unique finding in this study, this factor requires much
greater research into the links with falls prevention engagement and the extent of the
barriers and enablers it may convey.
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- It may also be worthwhile examining the impact of a single falls agency operating
within a pilot area which takes responsibility for coordinating and delivering falls
prevention for a period of time. This would test the suggestion that a single
information and intervention coordination centre would assist in raising the profile of
falls prevention within a locality to both older people and universal frontline staff,
through various communication and educational means.
- Where the recommendations above are tested or implemented, evaluation of their
impact, including costs, efficiencies, effectiveness and benefits should always be
incorporated into the work stream from the outset.
- Finally, it may be sensible to apply different research designs capable of answering
questions about the impact of interventions and the impact methods of engagement
have with interventions. These may include mixed method approaches, to include a
measure of the extent of impact, thus capturing what is inclined to work and why.
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APPENDICES
Appendix I: A Shortened Report on the Phase One Evaluation Study
STEADY on!
Evaluation of a Whole Systems Approach
to Community Falls Risk Awareness
Nicola Bell
Dr. Karen Whittaker
Dr. Chris Burton
Dr. Christina Lyons
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Abstract
This paper reports on an evaluation of a community based falls risk awareness
programme pilot. An innovative accident prevention programme was developed from
the KTP first stage theory-led evaluation findings (Whittaker et al., 2010), where five
themes (whole systems working, incentivisation, social marketing, learning theory and
promoting behaviour change) explained the success of a child accident prevention
intervention.
A process of knowledge translation enabled the learning from one context (children’s
accident prevention) to be transferred to a different context (older people’s fall
prevention). The falls prevention programme was delivered using a two-stream
approach involving front line staff providing universal services to the older population
and to older people in the community. Older people aged over 65 years and providers
of universal services (from health, social care, third sector and voluntary groups) were
identified and consulted with, contributing to the programme design. A series of
engagement events were held with the two participant groups, with social marketing
principles used to disseminate a branded message (based on the mnemonic ’STEADY’)
and tools reminding participants of the falls risks.
The aim is to make falls everyone’s business through integrating it within service
provision whilst concurrently embedding it into commissioning.
Following a pilot, the five themes identified as critical to the child accident prevention
intervention success were all positively evident in the ‘STEADY on!’ evaluation.
There is clear indication to support whole systems development of the programme.
Tailoring the message and materials whilst simultaneously raising the profile of falls
prevention in a socially acceptable manner contributes to capturing interest, marketing
and incentivising ‘STEADY on!’ across communities and organisations alike. How the
message is delivered to the participants encourages an active interest in the session.
The culmination of the four preceding themes promotes behaviour change; the
attention and action to minimise falls risks.
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Key words
Older people, falls, prevention, community, frontline staff, whole system
Key points
What is known about the topic
There are a number of risk factors associated with the likelihood of an older person
falling.
• Multi-method approaches appear to have some success in altering practices.
• Existing research has focused on measuring interventions, aimed at secondary
prevention.
What this paper adds
‘STEADY on!’ is an evidence-based, multifaceted community based falls risk
awareness raising programme.
The programme is a primary prevention intervention, socially acceptable to older
people and universal frontline staff alike.
‘STEADY on!’ is effective in raising the profile of falls risks and simple prevention
practices.
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Introduction
A fall is defined as “an unexpected event in which the participants come to rest on the
ground, floor, or lower level” (Lamb et al, 2005, p 1619). Falls are the cause of the vast
majority of fatal and non-fatal accidents involving people over the age of 65 years
(RoSPA, 2010; Age UK, 2010). The Department of Health (DH)(2009) identify falls as a
significant public health challenge, and the World Health Organisation (WHO)(2010)
has indicated that falls are the second leading cause of accidental or unintentional
injury deaths worldwide.
Current estimates are that one in three people over the age of 65 years will experience
at least one fall in a year (O'Loughlin et al., 1993). It is widely accepted that
complications from injuries increase with age. The implications of falls are wide
ranging creating human and growing financial costs to individuals and the NHS. For
example, where a fracture is sustained there is a minimum cost of £10,000 per patient
to the NHS, rising to £25,000 with additional and social care costs for a year (Parrott,
2000). Nationally, the population of those aged over 65 years is set to grow, estimated
at a 56.5% growth between 2010 – 2030 (Cheshire, 2005). It is evident falls is a growing
and expensive problem for communities.
Usually, no single risk factor causes a fall. There are often many contributing reasons
that increase a persons’ susceptibility to fall. These can be split into three categories;
extrinsic (environmental), intrinsic (personal) and behavioural risk factors. The dynamic
interaction between these factors makes the development of a specific intervention
difficult. Moreover, the heterogeneous relationship of risks and injuries confounds
efforts to develop interventions to reduce falls.
Interventions
There are a number of approaches to falls prevention to consider. Single focus
interventions have been much discussed as to their effectiveness compared to
multifaceted interventions that combine two or more components (Campbell and
Robertson, 2007; Hill-Westmoreland, 2002; Petridou, 2009). Chang et al. (2004)
concluded that whilst an exercise programme may be effective, single focus
environmental modification or education alone did not offer any significant benefit.
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According to Petridou et al., (2009), a single focus exercise alone intervention can be
up to five times more effective than a multi-focused approach. However this is only
applicable to short duration, low intensity, lower age and small sample programmes.
The limiting variables of this study are not suitable for replicating and sustaining across
a wider community. Overall, single focus interventions are often resource intensive
and their availability is often limited to smaller, high risk, secondary prevention
populations.
As falls are the result of several causes, a multifaceted intervention would seem a
rational approach to reduce several risk factors simultaneously. Reviews of evidence
point towards this strategy being the most effective (McClure, 2008; MacCulloch 2007;
Gillespie et al. 2003). Chang et al. (2004) identified a multifactorial assessment of risk
(comprising of drugs, vision, environmental hazards and orthostatic blood pressure)
coupled with a fall risk management programme as the most effective for reducing
both rate and risk of falls in older people. Similarly, Campbell and Robertson (2007)
concur that multifaceted interventions are effective for individual patients, and further
suggest that at a community level, multi-component programmes are as effective as
targeted single focus interventions. McKay and Anderson (2010) report that accurate
assessment, combined with targeted multi-disciplinary and multifactorial interventions
may achieve a substantial reduction in risk. Furthermore they suggest that early
assessment and intervention with ‘at-risk’ individuals is an emerging best practice. The
indication is towards community-based multifactorial initiatives with various
approaches and facets. There are undoubted issues to feasibly implement this;
resource constraints may impede the true spread of programmes. Still, given inevitable
pressures on public spending, to tackle multiple factors with the assumed more
effective strategy would seem the most appropriate approach to take (Campbell and
Robertson, 2007).
Engagement
McClure et al. (2005) recommend the involvement of the local community to optimise
how fall prevention is embedded. This said, most interventions target health care
personnel, encouraging practitioners to assume responsibility. DH guidance (DH 2006,
2009) encourages partnership working between existing services to work towards the
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common goal of preventing falls, although as Oliver (2009) comments, there are no
‘must do’s’ legislated for falls prevention. Different approaches and incentives are
recommended but not specified. The WHO (2007) highlights the latter point of
providing incentives and training for health and social care professionals. They argue it
is important to raise awareness of risks, best prevention practice and increase the skills
of the workforce to be able to advise on relevant healthy lifestyle practices.
Following consultation with a range of relevant practitioners and lay people, Yardley et
al. (2007, p233) developed a list of recommendations to be applied to falls
programmes. Three of these are promoting the immediate benefits of the programme
that fit with a positive self-identity, utilising a variety of forms of social encouragement
and addressing confidence in self-management of falls. All efforts should be focused
on raising awareness of risks to facilitate sustained behaviour change to reduce risks,
though Yardley et al. (2007) further acknowledge that a balance must be made in
keeping the intervention person-centred whilst maintaining the public profile of falls
prevention.
The programme
The STEADY on! programme was developed as part of a Knowledge Transfer
Partnership (KTP), tasked with translating best practices of accident prevention from
one context to another. An innovative accident prevention programme was developed
from the KTP first stage theory-led evaluation findings (Whittaker et al., 2010), where
five themes (whole systems working, incentivisation, social marketing, learning theory
and promoting behaviour change), under the direction of a transformational leader
explained the success of a child accident prevention intervention, ‘Action on Child
Accident Prevention’ (ACAP). A consultation and development process (reported
elsewhere) took place to translate the learning from the children and family
perspective to the new target audience; older people and falls. The aim is to make falls
everyone’s business through integrating it within service provision.
The programme was delivered using a two-stream approach involving front line staff
providing universal services to the older population and also to older people living in
the community. People aged over 65 years and providers of services (from health,
130
social care, third sector and voluntary groups) were identified and consulted with,
contributing to the programme design. A series of engagement events were held with
stakeholders develop the learning sessions. A branded message and tools (based on
the mnemonic ’STEADY’) was used to disseminate the message, reminding and
prompting participants of the falls risks.
The evaluation study
The aim was to examine the short and medium term impacts of ‘STEADY on!’, a
community based falls risk awareness programme. It primarily considered to what
extent the falls prevention awareness message has been raised and how it had been
received.
Methods
Two target groups were identified from the pilot site; older people and universal staff
who attended a STEADY on! pilot session. Older people from the local community
were aged 65 years and over and either lived in or attended social groups within the
pilot area. Universal frontline staff included those from health, social care, voluntary,
statutory and charitable organisations who worked within the pilot site and with older
people.
The sample was initially opportunistic, governed by the success of turnout for each
session. Once in attendance the sample for the study was both convenient as the
attendees were it situ, and purposive. The session was delivered to all attendees
however criteria were applied for evaluation inclusion (see Table 1). Various attempts
were made to engage non-English speakers through black and minority ethnic
organisations, including one Asian Elders men’s group, however to overcome the
language gap was beyond the scope and resources of the pilot.
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Table 1. Study Inclusion and Exclusion Criteria
Inclusion Criteria Exclusion Criteria
Older
People
Over the age of 65 years.
Older people who self-select to attend
services provided within the Hyndburn
locality.
Non English speaking and
reading
Non-residents of the
Hyndburn locality
Universal
Frontline
Staff
The staff included in the study have a
front line working role with older
people involving direct contact with
older people, working through
voluntary or statutory organisations,
such as the third sector organisation
‘carers link’ or services provided by
the NHS district nursing team.
Practitioners who do not
provide any services in the
Hyndburn locality.
Upon arrival at the session, the purpose of the pilot and the evaluation was explained
and an information sheet distributed. Attendees were informed that participation in
the evaluation was completely at their own choice and discretion. If they agreed in
principle to participate, a contact sheet was completed. This was not taken as consent
but as an expression of interest to be followed up. Once contact details had been
taken, the facilitator commenced the delivery of the session.
For those who gave consent to be followed-up for interview, contact was made by
telephone three weeks later. Participants were reminded of the study purpose and
verbal consent was re-confirmed. An interview was then arranged for a time, date and
venue convenient to the participant. Written consent was obtained at the beginning of
the interview.
Qualitative data were collected through observations and semi-structured interviews.
Observations of the sessions being delivered to the two target groups, universal staff
and older people, were taken. This included interactions between attendees and the
session facilitator and response to the delivery methods and demonstration of
resources. Interviews focused on capturing local intelligence regarding the perception
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of content, subsequent awareness of fall risk and alterations in falls related behaviours
following attendance at a ‘STEADY on!’ session.
Table 2 provides a summary of the participant types and indicates the data collection
mode. Observations of all 12 pilot sessions were recorded and 31 semi-structured in-
depth interviews were held (N=31). Table 3 shows the format of the interviews
undertaken.
Table 2. Type and Source of data collection
Data collection Data source Number
Observations n=12 Programme sessions 12
Interviews n=31 Older people 14
Universal staff 17
Table 3. Format of the interviews
Participant Interview Type N
Older People Face to Face 14
Universal
Staff
Face to Face – Individual
Face to Face – Paired
Telephone
8
6 (3 x 2)
3
Total n = 31
Data Analysis
Qualitative data were analysed following a process described by Miles and Huberman
(1994) whereby after collection, data were reduced, displayed and verified. This was
an iterative process which allowed reduction of the data until solid themes emerged
across all the cases. To achieve this, each transcription was read, and re-read, detail
analysed and key phrases of note highlighted and coded, initially according to the
concepts and themes identified in the ACAP Whole systems working model. Additional
themes were then identified, examined and explored.
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Ethical practice and governance
The proposal for this work was reviewed and approved by the Faculty of Health &
Social Care Research Ethics Committee, University of Central Lancashire. As the project
fulfilled the NHS criteria for evaluation, approval to proceed was granted by NHS East
Lancashire PCT through their Research and Development Manager, and the
programme manager of the East Lancashire Community Health Service. All data were
stored in accordance with University of Central Lancashire policies which are compliant
with the Data Protection Act. To preserve the identity of participants all names have
either been changed or removed.
Findings with Discussion
Table 4 presents an overview of the sample demographics.
Table 4. Interview participant sample
Older People Universal Services
Participants 14 Participants 17
Female 14 Organisations 8
Age 60-64
65-69
70-74
75-79
80-84
85-89
90-94
Other
0
1
1
4
6
0
2
0
Work roles Fire Safety Officer
Paramedic
Social Worker
RASO
Podiatrist
Community Matron
Occupational Therapist
Volunteer
Care Assistant
Senior Carer
Training Manager
Scheme Manager
2
1
1
1
1
1
1
1
1
2
1
4
Ethnicity White British
Asian British
13
1
Ethnicity White British
Asian British
16
1
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Themes
The interview findings are presented against the themes (Table 5) which the accident
prevention model was developed against, as identified in the child accident prevention
programme evaluation.
Table 5. Description of 5 key programme themes
Theme Description
Whole Systems
Working
Strategy for accident prevention shared and implemented across
all organisations and interested parties in a given locality.
Social Marketing Techniques used to raise the perceived importance of accident
prevention across key organisations and individuals
Incentives Financial incentives in the form of subsidised equipment, to affect
behaviour change
Learning Theory Facilitating an increase in knowledge as a precursor to behaviour
change
Promoting
Behaviour
Change
Facilitation of a change in behaviour that is commensurate with
best practice
In addition, these features operated under a transformational leader who provided a
vision and direction programme. In the KTP falls project, direction was most notably a
work-plan. This detailed the vision to be delivered; the translated accident prevention
programme for older people.
Whole System Working
This theme involves all parties collectively thinking about the way a programme is
delivered; not just focusing upon their own remit, but working towards a shared goal.
Sharing of resources
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Local residential communities and social groups were contacted to host older peoples’
sessions. Partner agencies were willing to provide facilities for the staff training
sessions and welcomed outside organisation attendance.
Expressing an interest
Uptake of the programme by stakeholders was very positive. A single round of
advertisements secured over subscription to the pilot sessions, indicating a high level
of interest in falls prevention and demand to provide training. It appeared that
attendees, through talking about the sessions, endorsed the programme amongst their
peers generating additional requests to attend the training.
It was advertised on a social leaflet. Doug saw it [neighbour], said it would do
me good. (OP. H)
Organisational space
Leadership allowed universal staff autonomy of their time and activities; the freedom
to choose to attend. Some organisations upheld a direct command for staff to attend
the training; however, practitioners had the autonomy to make their own decision to
attend.
I heard about the training via an advert up on the notice board – it wasn’t
mandatory but I wanted to gain more information about falls and how to
prevent them.
(P. P)
Universal staff welcomed the opportunity to meet with other organisations that have
similar, if not overlapping responsibilities and values towards older people.
It’s nice to know there are other people out there that are dealing with falls. It
weren’t just the responsibility of the ‘x’ team that had took it on, because
honestly, I thought it was. (P.N)
Workers want and need to be encouraged to build relationships with other
professionals again. (P. J)
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Practitioner J further commented on the disappointment that more team members
had not attended the training. I don’t think they didn’t want to attend but couldn’t due
to work loads and commitments. A clear reflection on the busy the schedules of
workers and the expectation and demand put upon them. This supports the imperative
to work together to address a common issue, assisting in preventing something as
simple as falls.
Involvement
As practitioners met at the sessions, opportunities to share their experience and learn
from each other arose. Collaborative efforts towards the identified shared goal (falls
prevention) were appreciated and belief was evident in the concept of collective effort
producing a greater reward or impact.
There were all sorts of people there at the training, so people are coming at it
[fall prevention] from every angle. (P. J)
Sharing of information produces a positive outcome as knowledge of local services is
communicated between practitioners. This raises the awareness of local systems to
help fall prevention and other areas of health need, as Practitioner P discussed.
I didn’t realise that there are people who you can get more advice and support
from if you know a person is at risk of a fall or has just had a fall and needs
additional support in the short term.
Social Marketing
Social marketing is the application of marketing concepts to achieve a specific socially
desired outcome (National Social Marketing Centre for Excellence, 2005).
Tailoring
Adapting the style to suit a particular audience or situation is called tailoring (Graham
et al., 2006). The ethos of the programme, ‘falls prevention is everyone’s business’
was congruent with many opinions of universal staff. When asked Whose responsibility
do you feel falls are?, universal staff replied;
A combination of everyone pulling together, it has to be. It can’t all be put on
the one person’s shoulders. (P.E)
137
However, older people felt they were more personally responsible for managing their
falls risks, as illustrated when asked the same question.
You can’t say the NHS, it’s up to people themselves to be sensible at it.
(OP. L)
The differing perspectives of practitioners and older people highlights the value in
approaching the learning needs separately. It supports the decision to deliver a two
stream approach, tailoring the delivery to the audience.
Materials
To accompany the two perspectives, different types of promotional materials were
produced. These included a diary sticker and workplace posters for universal staff, tea-
towels for older people, and posters and prompt cards for community locations. The
purpose of these materials was to promote awareness of the campaign and remind
participants of the content of the session (the ‘STEADY’ message). The provision of
these materials was well received and they were widely used.
It [tea- towel] is very good. I mean, as I say, my little friend Penelope, she has it
on the wall so she has all the information there. Her memory is not very good.
(OP. I)
It [the sticker, affixed to diary front] is just there and to hand. We take our
diaries everywhere. (P.A)
This evidence supports the appropriateness of using a diary sticker for universal staff,
as it emphasises the importance of a diary to practitioners. In addition, participants
noticed the presence of the messages in community locations, such as Practitioner 1
who saw one of your posters in Asda the other day.
The simplicity of the ‘STEADY on!’ message was recognised as being communicable to
ethnically diverse populations. The tea-towels attracted attention from families and
across cultural boundaries. For example, during the pilot phase and whilst on GP
premises there was specific interest in the imagery used on the tea-towels.
138
Attraction of young Asian children to the tea-towels via use of cartoons, turning
to show parents and family the tea-towel, sharing the message across
generations of families. (Field-notes)
Profile raising
To local populations, ‘steady’ was a word synonymous with preventing or acting to
prevent a fall occurring, without mentioning the ‘fall’ word.
It’s something I might say you know, to someone walking too fast; slow down,
STOP, don’t go running off, you might fall. (OP. G)
The programme raised awareness of falls risks and simultaneously increased the
profile of the community falls team.
I just learnt that they [falls team] existed. (P. N)
Furthermore, the merits of the ‘STEADY on!’ project were positively acknowledged by
local GPs and health/social care managers. Although they did not attend any of the
sessions, they endorsed the delivery and dissemination of the ‘STEADY’ message. As
one local stakeholder commented, I can see the value of the programme for the local
community, definitely.
Incentives
To complement and marry with social marketing, incentivising involves identifying and
using factors which encourage engagement with a programme.
Individual
Completion of the programme entitled attendees to receive a number of ‘STEADY on!’
materials and tools. These tools could be viewed as a partial incentive and reward for
attending. This is an example of how social marketing and incentivising begin to
overlap, as older people and universal staff who haven’t attended the programme
request materials and awareness starts to spread. In addition, all universal staff who
139
completed the session received a certificate of attendance in support of their personal
professional development.
Researcher witnessed a number of certificates shown on the walls of workplace
environments. (Field-notes)
Displaying the certificates too shows attendance and sense of value in the training
undertaken. Similarly, a number of staff and older people individually asked after their
sessions if they could have additional materials to take away with them for colleagues
and relatives. This emphasises the value placed on the training delivered and the
requirement for wider promotion of falls prevention.
I doubled up and took two lots of extras for two other schemes as well.
(P. O)
Marketing the sessions with NHS branding and community falls team logo provided
recognition that the training would be supported and delivered by experts in the field.
This also offered assurance to external organisations that their existing practice was
allied to that of the experts. As a provider of domiciliary care firm discusses,
P - We do most if it anyway, almost all of it.
R - How did it make you feel if you came away thinking you did most of it
anyway?
P - It made us feel good because we know we were doing it right, we’re doing
something right. (P. I)
This evidence emphasises the value the practitioner places on wanting to deliver best
practice in the correct manner. Other practitioners commented on the session’s
usefulness because falls are so relevant to their clients’ situations. The motivation to
attend the training is to be able to provide an enhanced service to older people.
It’s good to go and get more knowledge on problems that are relative to the
people you work with. If you can get that and bring it back to work, it’s adding
to the skills you offer them. (P. E)
Organisations
140
Although provided free to all organisations, the staffing cost must be realised by the
training providers as staff attending must have their work responsibilities covered by
other staff. This is illustrated by Practitioner I, a provider of domiciliary care.
Desirable as it’s free and short and sweet. Even when free, when we release
someone to go training, we have to pay for their time and someone to cover
their work…. we haven’t got all that much money ….. So free, and short, we can
live with that. For 3 hours or a full day, I would have gone, and no one else.
Unless you have to, HSE [Health and Safety Executive] or something. That’s
different.
As pointed out, because falls prevention isn’t mandatory, part of the appeal of the
training is the minimal additional burden to organisations who wish to send staff.
There are few demands by comparison to some training courses; time reduced for
travel and no fee, even to non-NHS organisations.
Towards the pilot end, focus turned to the financial commitment required for the
programme. Pilot costs had been budgeted; these were extrapolated and finances
calculated to rollout the programme across a wider footprint. At an organisational
level, the stimulus to invest in the programme is supported by the relatively small
investment cost for programme delivery, matched against the escalating costs of falls
as injury severity increases.
Learning
Facilitating an increase in knowledge about falls risks acts as an antecedent to
behaviour change.
The session
The use of interactive delivery methods encouraged two-way exchange between the
session facilitator and attendees. Participants from both types of audience were
delivered the key ‘STEADY’ learning points using a memory tray game. This was
intended to stimulate the memory of ‘STEADY’ risks through visual association to
items. Practitioner A referred to the tray as all the gizmo’s she brought before recalling
four of the six key ‘STEADY’ risks.
141
They were helping you weren’t they, yes. They were putting into your head
what to do like, yes, and helping you to get things. (OP. F)
The sessions were intended to be active and fun: an enjoyable approach to delivering a
serious message.
Clients have fed back that they both enjoyed and learnt from the sessions. …..
And the banter, they remember that. It helps the topic stick in their minds.
(P. E)
Engagement and positivity
Where some older people were attending a regular social group where ‘STEADY on!’
was featured as the guest presentation, some negativity was noted upon the
announcement of fall prevention being the topic.
I thought we were having a quiz; I wouldn’t have come if I’d know it was falls!
(OP. 2)
However as the session progressed, those who had protested increasingly engaged,
with positive comments being passed at the end.
Pessimism gone by end; comments that everyone had learnt something and
very much enjoyed themselves (Field-notes)
Thank you, that’s been really helpful (OP. 3 to facilitator)
In addition to this point researcher field-notes recount that a number of universal staff
attendees looked a little apprehensive upon entering the session. However, as all
sessions progressed, a sense of positivity was witnessed as all attendees engaged with
the programme and expressed a willingness to act.
Most cases I see are due to falls and poor carers. It’s such a shame. But it’s
wonderful that we now have this for falls..... I’ve told my friends and family as
well. (P. C)
Older people enjoyed the opportunity to openly talk and discuss falls within a safe and
unassuming environment, whilst staff welcomed the insight and guidance into helping
those that they commonly work with.
142
Well everyone was together in a group, talking about the same thing. It felt like
someone was caring, someone was concerned. If you don’t see anyone, no one
ever does anything. I feel happier because someone’s bothered and I could pick
up a phone. You don’t feel as alone. (OP. N)
This demonstrates the value the older people felt by having NHS taking the time to
address and discuss a significant matter with them. The inclination is that a positive
impression has been made by the local NHS, both for the time taken to speak to older
population and to address the subject itself.
Promoting behaviour change
By bringing different organisations together to learn, the same key messages about
falls risks are disseminated. Concurrent delivery of the key messages to older people
enables a reinforcement of facts and repetition was an aid to remembering the
knowledge learnt.
R - Have you ever heard of fall prevention from any other sources?
OP - Yes, I have a girl who comes to do my nails [pointed to feet]. She comes
from Burnley and I had it [reminder card] on the table….I had it on the table and
she said, oh, I was going to give you one of those. .... She’s called ‘Rose’, ... from
Caremart, yes, Caremart. (OP. K)
This is an example of whole systems working: Caremart are a non-NHS agency
providing a low-cost toe nail cutting service to clients. When ‘Rose’ commented to
‘Older person K’ on the presence of the reminder card, it highlighted the ‘STEADY’
message. The message delivered was consistent; i.e. ‘STEADY’, and it’s repetition from
a different source brought falls awareness to the attention of the older person again.
Desire to do the right thing
Practitioners with similar values based on improving the wellbeing and health of older
people welcomed the training as a means of learning to be able to do more for their
clients. As Practitioner E commented:
Before the training I just hoped the GPs would pick up on the falling and refer
the person appropriately. Now we can take it into our own hands and have
143
more direct contact. There’s someone there if I need it, and assistance for the
service user.
The inclination and willingness to act, coupled with the value of having the contact to
do something meant a lot to Practitioner E. Similarly for Practitioner F who wouldn’t
have thought to refer on to anyone else as the client in question had called an
ambulance out that had attended many times. Practitioner F concluded, adding:
It’s good that there is another option; I thought everything was in place that
needed to be there.
This also indicates the importance of having a telephone number for the programme
to be most successful. A single access point is required to ensure that both universal
staff and community members have a point of contact to act on reducing falls risks.
I think your phone number’s your lifeline.....it makes me think, right, this is
where I go now. That there’s somebody at the end of it [the telephone line].
(P. N)
Falls prevention action
Participants described how they had taken action on falls risks and made changes to
their behaviour to minimise falls risks following a ‘STEADY on!’ session.
Practitioner M described how the session had prompted the team to address the
question ‘Do you Fall?’ as highlighted at the training in a team meeting.
At the first team meeting after the training, asking the question became an
agenda item. .... We should ask it but not many people actually did. Our team
leader wanted the implementation of routinely asking the question..... now the
question, ‘Do you fall?’, we ask it more.
Likewise, older people discussed examples of preventative behaviours since the
session.
Oh, yes, a light bulb.... I remember stairways and hallways and thinking I had
one less thing to think about because I’ve no stairs. I came back and checked my
144
bulbs and then I had to call someone because the main one up above the front
door had gone. (OP. L)
Older person C talked about preventative changes using the campaign title, ‘STEADY’.
This again supports both the social marketing strategy to use this word in association
with falls, and the learning through the repeated, consistent, positive message.
I talked to myself, tried to do what I’d heard, seen. It was a good afternoon,
what we learnt, made me more alert. I always try to get myself steady.
(OP. C)
Conclusion
The five themes identified as critical to the success of the child accident prevention
programme were all positively identified and evident in the ‘STEADY on!’ evaluation.
There is clear indication to support whole systems development of the programme.
Sharing resources, allowing organisational space, expression of interest and
involvement in the sessions all substantiate the ethos to work together towards a
common goal.
Tailoring the message and materials whilst simultaneously raising the profile of falls
prevention in a socially acceptable manner contributed to capturing interest and
marketing the ‘STEADY’ message across communities and organisations alike. Building
on this, the raised awareness of the programme will both contribute to and draw upon
whole systems working.
Providing motivating factors for attendance and involvement in a programme does not
always have to be financial, but incentivising nonetheless. Promoting the benefits of
attending the programme through social marketing strategies can be reason enough
for individuals; for organisations, the sharing of resources through whole systems
working enabled the programme to be delivered free of charge to attendees.
How the message is delivered to the participants encourages an active interest in the
session. Local information is shared, enhancing learning beyond the formal ‘STEADY
on!’ key messages. Networking is an incentive for universal services to attend,
allowing professional relationships to develop. It can be seen that the five themes start
145
to come together and overlap as a wholesome framework working towards a common
goal.
The culmination and collaboration of the four preceding themes promotes behaviour
change; the attention and action to minimise falls risks. Older people are prompted to
be more self-aware whilst universal services apply the knowledge learnt when working
with older people. ‘STEADY on!’ provides a reminder/checklist of common falls risks
whilst also providing a telephone contact for gaining further help and information,
enabling action to be taken when risks are identified. Behaviours are altered, allowing
people to move from the position of reacting to risk factors once a fall has occurred, to
being pro-active and addressing the risks factors to prevent the fall before it has a
chance of happening.
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Appendix 2: Lexicon
Engagement: The practice of being alert, involved and actively paying attention to
something or someone. With regard to this study, it is the aptitude or process of
gaining and occupying a person’s awareness and effort in a falls prevention
intervention (described below).
Falls Prevention Intervention: This term refers to the deliberate action or product of
involving someone or something in an attempt to minimise the risk of falling over. It is
used here to refer to all possible falls prevention services and activities; direct (to the
person) and indirect (of their environment); delivered in groups, as education or
training; the provision and use of aides and adaptions, and sources of personal (family
and friends) and professional assistance for falls prevention. In effect, falls prevention
intervention is used as a pragmatic umbrella term.
Stakeholder: This is a person or group of people who have an interest in or who are
affected by a subject, activity or project. In this study, the stakeholders have an
interest in falls and preventing falls by older people because they either are an older
person, or they have a responsibility for the care and welfare of older people as part of
their work role. That is, they hold a stake of interest in the intention or outcomes of
preventing falls.
Stakeholders are taken to be both older people (typically aged 65 years and over) and
frontline staff from health and social care, charitable, voluntary and statutory services
who work directly with older people.
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Appendix 3: NHS East Lancashire Programme Manager Approval to Proceed
150
Appendix 4: NHS East Lancashire Research and Development Approval to Proceed
151
Appendix 5: Approval of Phase One Study by UCLan Ethics Committee
28th October 2010
Karen Whittaker/Nicola Isaacs/Christina Lyons
School of Nursing and Caring Sciences
University of Central Lancashire
Dear Karen, Nicola & Christina
Re: Faculty of Health & Social Care Ethics Committee (FHEC)
Application - (Proposal No.449)
The FHEC has granted approval of your proposal application ‘Evaluation of Falls Risk
Awareness Programme’ on the basis described in its ‘Notes for Applicants’.
We shall e-mail you a copy of the end-of-project report form to complete within a
month of the anticipated date of project completion you specified on your application
form. This should be completed, within 3 months, to complete the ethics governance
procedures or, alternatively, an amended end-of-project date forwarded to Research
Office.
Yours sincerely
Peter Robinson
Deputy Vice Chair
Faculty of Health Ethics Committee
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Appendix 6: Registration Approval for MSc Study (Phase Two), Incorporating Ethics
Committee Approval
21st September 2011 Nicola Bell 46 Rose Lane Preston PR1 6HJ Dear Nicola
REGISTRATION FOR THE AWARD OF RESEARCH DEGREE OF THE UNIVERSITY OF CENTRAL LANCASHIRE
I am pleased to inform you that the SWESH Research Degrees Sub-Committee has approved your registration on a PART time basis for the degree of Master of Philosophy. Title of Programme of Research What are the challenges to engaging stakeholders in fall prevention? Supervisors Karen Whittaker (Director of Studies) Beverley French (Second Supervisor 1) Christina Lyons (Second Supervisor 2) Date of Registration and Duration of Programme The expected period of registration is 24 months with effect from January 2011, subject to conditions specified in the University Regulations. The expected date for submission of your final thesis is 31st December 2012. Examination Arrangements a) The arrangements for examining you on your programme of work. b) The external and internal examiners to be appointed. These arrangements should be submitted no later than 4 months before you propose to submit your thesis for examination. Please note that you will not be able to submit your thesis until examination arrangements have been approved. Please feel free to contact me about any aspect of the registration procedures or with any other queries you may have. Yours sincerely Clare Wiggans On behalf of the SWESH Research Degrees Sub-Committee Copies: DoS SS1
SS2 RDT
153
Appendix 7: Ethical Considerations Applied to the Study
Ethical
Consideration
Response
Non-Maleficence (to
do no wrong or
harm)
If an older person were to get upset during the interview, the older person would be given the opportunity to
pause or stop the interview. It would only be restarted when the older person indicated they were happy to
continue and consent was regained.
If an older person started to share information about an incident that suggesting the older person was at risk
from harm, the interview would be terminated and the interviewer would follow the safeguarding vulnerable
adults policy for the local Primary Care Trust (NHS East Lancashire) and inform their Director of Studies and
the safeguarding vulnerable adults team.
The interviewer would carry contact details to be left with the older person of relevant agencies for further
help and advice to be found, e.g. their local Age UK.
Interviews would take place at a pre-arranged time at the convenience of the stakeholder.
Beneficence
(to do good)
Falls prevention programmes are intended to promote the prevention of falls and thereby promote the health
and wellbeing of older people through numerous means.
The knowledge gained by the study allows refinement of the falls prevention programme to shape
intervention development with stakeholders in mind, considering and encouraging sustained uptake of the
programme for the benefit of older people.
Dissemination of the study results via a number of outputs to contribute to the knowledge base.
Justice Of the opportunistic, purposive sample from the STEADY on!’ evaluation, participants were invited for follow-
up interview (phase two) using purposive sampling.
Respect for
Autonomy
(to self-govern)
Cont. Respect for
Autonomy
Stakeholder participation in the study was completely voluntary.
Participants were provided with study information sheets and were able to ask questions before, during and
after the study.
All participants gave their informed consent to participate.
Participants remained free to withdraw at any time from the study, without giving a reason, even once
consent was obtained.
154
Ethical
Consideration
Response
(to self-govern) Non-participation did not affect any services stakeholders received or the manner in which they were
communicated with.
155
Appendix 8: Information Sheet Provided to Participants – Older People
Page 1 of 2
Challenges to Engaging Stakeholders in Falls Prevention
An Information Sheet for Follow-up Interview – Community Members
Following the Evaluation of a Pilot Falls Awareness programme (‘Steady On!’) delivered by East
Lancashire Community Health Services in partnership with the University of Central Lancashire,
you are being invited to take part in a follow-up interview. This is for a Masters by Research
project referred to during the ‘Steady On!’ evaluation. Before you decide to take part it is
important for you to understand why the study is being done and what it will involve. Please
take time to read the following information carefully and discuss it with friends, relatives and key
workers from services you receive if you wish. Take time to decide whether you wish to take
part. If there is anything that is not clear, or you would like more information, please ask us. If
you do decide to take part you will be asked to for your consent.
To help you in your decision to be involved in the study, some common questions and their
answers are listed below. Thank you for reading this and we hope you find the following
information helpful.
What is the purpose of the study?
This study is building on the evaluation of ‘Steady On!’. The researcher, Nicola Bell (nee Isaacs) is
now undertaking a Masters by Research. The study will examine “what the challenges are to
engaging stakeholders (older people aged 65 years and over and universal frontline staff working
with older people) in falls prevention”. This involves exploring the opinion of community
members on barriers and enablers to acknowledge and value falls prevention. Of particular
interest are views on what a fall is and the opportunities and challenges to engaging with and
participating in community falls prevention activities.
Why have I been chosen?
As a participant of the ‘Steady On!’ pilot evaluation, you indicated at the end of the interview
that you could be contacted for a follow-up interview. Whilst you have been approached for a
follow-up interview, it is entirely your decision whether you take part.
What will happen if I take part?
If you agree to take part in a follow-up interview, any falls prevention services that you receive
will not be altered in any way. Nicola Bell, the Masters by Research student, will telephone you
to ask if you would like to take part in a short interview, either in person or on the telephone. A
face-to-face interview would take place either at your home or another location convenient to
you. Nicola will want to audio record your conversation and will ask your permission before
doing this. She will ask that you sign a consent form (if a face-to face interview) or give verbal
consent (if a telephone interview) to indicate and record your agreement to be involved in the
study. The appointment will be at a time convenient to you. It is anticipated that Nicola’s
discussion with you about falls prevention will last approximately 30 – 60 minutes.
So that you can confirm who she is, Nicola Bell will carry a University identity card.
Do I have to take part?
It is up to you whether you decide to take part. If you do decide to take part please keep this information sheet for reference. If taking part you will be asked to give written or verbal consent to show your agreement, but if you change your mind at a later date you will still be free
156
Page 2 of 2
to withdraw and without giving a reason. This will in no way affect any falls prevention services
you work receive.
What sort of questions will be asked during the interview?
Examples include:
Can you describe what ‘a fall’ is to you.
What sort of things do you do to prevent falls?
Would you consider seeking help or advice to prevent falls?
Will my taking part in the evaluation be kept confidential?
All information you provide during the course of the study will be kept strictly confidential. Your
name and contact details will stored separately from details of the interview. With your
permission, the researcher will audio tape the discussion with you in order to make best use of
the information shared. The audio copy will be transcribed and you will be offered the
opportunity to have a copy so that, if you wish, you can confirm its content and authenticity.
The audio copy will then be destroyed. All names will be removed for data protection and
anonymity. Only members of the Masters by Research supervisory team will have access to the
interview transcripts and these will be stored in a locked University cabinet for a 5 year period,
after which they will be shredded, or will be stored on a password protected UCLan computer or
data encrypted memory stick.
The rights of confidentiality would only be broken if there were concerns about the protection of
a vulnerable adult. In this situation the researcher would be obliged to follow the safeguarding
vulnerable adults policy of NHS East Lancashire. However information would not be shared
without your knowledge. A copy of the safeguarding vulnerable adults policy can be obtained
from the NHS East Lancashire Primary Care Trust, 01282 644700, www.eastlancspct.nhs.uk .
What if I change my mind?
You have the right to change your mind about taking part in the evaluation at any time, by
contacting Nicola Bell (details below).
If something was to go wrong
If you want to make a complaint about the evaluation, you can contact the Head of School of
Health at the University of Central Lancashire on tel: 01772 893700.
What will happen to the results of the study?
The Masters dissertation will be available by September 2013. You may request a copy of this by
contacting Nicola Bell. Results from the study may also be published in appropriate peer
reviewed journals, for example ‘Injury Prevention’.
Who has reviewed this evaluation?
The Faculty of Health Ethics Committee at the University of Central Lancashire has reviewed this evaluation.
Thank you for your interest in this study. To find out more about the study please contact;
Nicola Bell Tel: 01772 893608 Email: [email protected]
MRes OP Follow-up Info Sheet 23-8-2011 v3
For further information about the Falls Team, East Lancashire Hospitals Trust, Community Division, Please contact; Diana Hebden, Falls Co-ordinator or
Yvonne Skellern-Foster, Falls Community Partnership Lead on Tel: 01200 420678
157
Appendix 9: Information Sheet Provided to Participants – Universal Frontline Staff
Page 1 of 2
Challenges to Engaging Stakeholders in Falls Prevention
An Information Sheet for Follow-up Interview – Universal Frontline Staff
Following the Evaluation of a Pilot Falls Awareness programme (‘Steady On!’) delivered by East
Lancashire Community Health Services in partnership with the University of Central Lancashire,
you are being invited to take part in a follow-up interview. This is for a Masters by Research
project referred to during the ‘Steady On!’ evaluation. Before you decide to take part it is
important for you to understand why the study is being done and what it will involve. Please
take time to read the following information carefully and discuss it with friends, relatives and
colleagues if you wish. Take time to decide whether you wish to take part. If there is anything
that is not clear, or you would like more information, please ask us. If you do decide to take part
you will be asked to for your consent.
To help you in your decision to be involved in the study, some common questions and their
answers are listed below. Thank you for reading this and we hope you find the following
information helpful.
What is the purpose of the study?
This study is building on the evaluation of ‘Steady On!’. The researcher, Nicola Bell (nee Isaacs) is
now undertaking a Masters by Research. The study will examine “what the challenges are to
engaging stakeholders (older people aged 65 years and over and universal frontline staff working
with older people) in falls prevention”. This involves exploring the opinion of frontline staff,
(including health and social care, charitable, voluntary and statutory services) on barriers and
enablers to acknowledge and value falls prevention. Of particular interest are views on what a
fall is and the opportunities and challenges to engaging with and contributing to community falls
prevention activities.
Why have I been chosen?
As a participant of the ‘Steady On!’ pilot evaluation, you indicated at the end of the interview
that you could be contacted for a follow-up interview. Whilst you have been approached for a
follow-up interview, it is entirely your decision whether you take part.
What will happen if I take part?
If you agree to take part in a follow-up interview, any falls prevention services that you link in
with will not be altered in any way. Nicola Bell, the Masters by Research student, will telephone
you to ask if you would like to take part in a short interview, either in person or on the
telephone. A face-to-face interview would take place either at your place of work or another
location convenient to you. Nicola will want to audio record your conversation and will ask your
permission before doing this. She will ask that you sign a consent form (if a face-to face
interview) or give verbal consent (if a telephone interview) to indicate and record your
agreement to be involved in the study. The appointment will be at a time convenient to you. It is
anticipated that Nicola’s discussion with you about falls prevention will last approximately 30 –
60 minutes. So that you can confirm who she is, Nicola Bell will carry a University identity card.
Do I have to take part?
It is up to you whether you decide to take part. If you do decide to take part please keep this information sheet for reference. If taking part you will be asked to give written or verbal consent to show your agreement, but if you change your mind at a later date you will still be free
158
Page 2 of 2
to withdraw and without giving a reason. This will in no way affect any falls prevention services
you work with.
What sort of questions will be asked during the interview?
Examples include:
Can you describe what ‘a fall’ is to you.
What sort of things do you do to prevent falls?
Would you consider seeking help or advice to prevent falls?
Will my taking part in the evaluation be kept confidential?
All information you provide during the course of the study will be kept strictly confidential. Your
name and contact details will stored separately from details of the interview. With your
permission, the researcher will audio tape the discussion with you in order to make best use of
the information shared. The audio copy will be transcribed and you will be offered the
opportunity to have a copy so that, if you wish, you can confirm its content and authenticity.
The audio copy will then be destroyed. All names will be removed for data protection and
anonymity. Only members of the Masters by Research supervisory team will have access to the
interview transcripts and these will be stored in a locked University cabinet for a 5 year period,
after which they will be shredded, or will be stored on a password protected UCLan computer or
data encrypted memory stick.
The rights of confidentiality would only be broken if there were concerns about the protection of
vulnerable adults. In this situation the researcher would be obliged to follow the safeguarding
vulnerable adults policy of NHS East Lancashire. However information would not be shared
without your knowledge. A copy of the safeguarding vulnerable adults policy can be obtained
from the NHS East Lancashire Primary Care Trust, 01282 644700, www.eastlancspct.nhs.uk .
What if I change my mind?
You have the right to change your mind about taking part in the evaluation at any time, by
contacting Nicola Bell (details below).
If something was to go wrong
If you want to make a complaint about the evaluation, you can contact the Head of School of
Health at the University of Central Lancashire on tel: 01772 893700.
What will happen to the results of the study?
The Masters dissertation will be available by September 2013. You may request a copy of this by
contacting Nicola Bell. Results from the study may also be published in appropriate peer
reviewed journals, for example ‘Injury Prevention’.
Who has reviewed this evaluation?
The Faculty of Health Ethics Committee at the University of Central Lancashire has reviewed this evaluation.
Thank you for your interest in this study. To find out more about the study please contact;
Nicola Bell Tel: 01772 893608 Email: [email protected]
MRes US Follow-up Info Sheet 23-8-2011 v3
For further information about the Falls Team, East Lancashire Hospitals Trust, Community Division, Please contact; Diana Hebden, Falls Co-ordinator or
Yvonne Skellern-Foster, Falls Community Partnership Lead on Tel: 01200 420678
159
Appendix 10: Sample Consent Form for Participants
School of Health
Brook Building
University of Central Lancashire
Preston PR1 2HE
Telephone: 01772 893608
e-mail: [email protected]
www.uclan.ac.uk
CONSENT FORM
Title of Project:
Challenges in Engaging Stakeholders in Falls Prevention
Name of Researcher: Nicola Bell Karen Whittaker
Please initial box
1. I confirm that I have read and understand the information sheet dated ............................ (version ............) for the above study. I have had the opportunity to consider the information, ask questions and have had these answered satisfactorily.
2. I understand that this is a follow-up interview, based on my 3. participation in the Evaluation of a Falls Risk Programme.
4. I understand that my participation is voluntary and that I am free to withdraw at any time, without giving any reason.
5. I understand that my name will not be included in any part of the study.
6. I agree to the discussion with the researcher being audio taped.
7. I agree to take part in the above study and the data to be used for the Masters degree being undertaken by the researcher, Nicola Bell.
________________________ ________________ ____________________
Name of Participant Date Signature
_________________________ ________________ ____________________
Researcher Date Signature
1 for participant: 1 for researcher
MRes Consent Sheet 11-7-2011 v1
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Appendix 11: Interview Preparation and Schedule
161
162
Appendix 12: Extract from Phase Two, Part One Notes – Recording the Themes and
Codes used to Annotate Secondary Review of Phase One Data
163
Appendix 13: Early Image of Data Reduction following Part Two Analysis
164
Appendix 14: Refined Image of Data Visualisation following Part Two Analysis
165
Appendix 15: Example Exploring the Interpretation of ‘Support’ Theme
166
Appendix 16: Case Participant Descriptions
Stakeholder 1
Phyllis has lived in sheltered accommodation for the past 18 years. She originally
moved there with her husband who has since passed away. She suffers from diabetes
for which she has an annual check-up at the local health centre and has recently
started using a walking stick at her own direction as she is suffering from a bad hip. In
addition, Phyllis visits the local nurse every three months and has her medication
reviewed regularly. She has, touch wood, never fallen. Phyllis leads an active lifestyle,
where she goes out every day, even if it’s only for an hour and more often than not
meets up with friends, some of whom also live in the same complex. Phyllis doesn’t
have a car so walks, gets the bus or a taxi. She has family who live locally – a bus
journey away. If the weather is bad, her family will come in the car to help her do her
shopping. She has no domiciliary or home care assistance and appears proud of the
fact.
Her accommodation is not cluttered but not sparse, with a couple of rugs on the floor.
Phyllis is knowledgeable of her neighbours and can list those known to fall frequently.
Stakeholder 2
Penny is aged 80-84 and lives alone in supported accommodation. She has domiciliary
homecare services to assist her with some activities of daily living for a few hours
across a few days of the week. Penny has had a physical disability since childhood, and
has consequently always worn stepped footwear to balance and manage her gait.
However Penny has not led a restricted life due to this: she reminisces about dancing
every night and going every week hiking too. Sunday afternoon every week, a good 10
mile walk. In older age, Penny has arthritis but gets by with her carer, and a son, and
167
some very good neighbours. She manages to get out to the local shops if she goes
down the [train] line and takes her time. To help her do this, Penny has recently bought
a stick and a wheeler [wheeled shopping trolley] of her own volition. Although she has
not fallen in the previous 12 months, she did fall within the residential complex
without serious injury within the past 24 months and can recount the incident with
good clarity.
Stakeholder 3
Living independently in her privately owned home, Paige is 75-79 years, suffers badly
with arthritis in most of her joints and has recently had a knee replacement operation.
She is currently waiting for the second to be similarly operated on. She has fallen a
couple of times within the past 12 months. Prior to that, she fell about 18 months ago
whilst in a public park and it took all her confidence from her. She hasn’t really ever got
that confidence back. She also recalls moments where she catches herself just in time
before she actually falls to the floor.
Paige doesn’t receive any domiciliary support but has been provided with a couple of
home adaptations through occupational therapy and social services since her knee
replacement. She reports using some of these but also finds some of the items
unhelpful. She started using her late husband’s walking stick and has since been out
and bought more feminine versions for when she does venture out of the house.
However she does feel more confident if she’s got someone to go out with – not
holding or anything, just having them there. Paige has three daughters but they don’t
live close by. She uses her mobile telephone as a daily communication tool/ emergency
alarm to keep in contact with one daughter in particular.
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Stakeholder 4
There are many ticking clocks in the living room at Pattie’s sheltered accommodation
bungalow. Pattie is hard of hearing and suffers from a number of ailments and long
term conditions. She tries to find everything that’s going to help her, such as the visual
and vibrating smoke alarm systems fitted in the property. Pattie also has a pendant
alarm system fitted but prefers to keep the pendant by her bedside rather than on her
person.
Pattie is 80 and has domiciliary care come for an hour every day and for an extra hour
on a Monday to assist with the shopping. On a Tuesday she goes to the local church for
a social/ exercise group with three neighbours and which she likes, and it’s to music,
and it’s good. Try and stop me going, emphasises how Pattie feels about it.
Pattie has family that live within the same town who visit regularly for social contact.
Pattie does have a history of falling, and recalls three falls within the past six months.
She has mentioned the falls to the lackadaisical GP but thinks falls must happen to
everybody. What can they [NHS] do?
Stakeholder 5, Stakeholder 6
Married for 50 years in the year of the Golden Jubilee, Peggy and Percy are in their 80’s
and live in a private residential first floor flat. Percy had a stroke 18 years ago but has
regained mobility to allow him to walk with a stick, drive and continue living in the flat
with a couple of adaptations. They have no other long terms conditions or ailments.
The couple have children with families who live in other parts of the country. They do
not have any domiciliary assistance but talk about coming to their neighbours’ aid on a
number of occasions for practical and falls related needs. They appear very house
proud and are defensive of the one rug which is in front of the fire place in the living
169
room, because otherwise Percy will wear a hole in the carpet with his good leg (a habit
of rubbing the carpet whilst watching the TV).
The couple both speak of experiencing falls but not for a long, long time (many years).
Percy served in the Military Forces and has shared with Peggy some techniques to help
manage a fall to help avoid more serious injury, where the fall cannot be avoided.
Stakeholder 7
Simon has been an engineer all of his working life. Upon retiring he became a
volunteer at a local day centre for the elderly and infirm. He helps at this one day a
week performing a number of activities to help out the staff, other volunteers and the
older people who attend. Duties include conversing, serving food and drinks,
mobilising, playing games, co-ordinating activities and generally assisting the older
people as they request. Simon has found this change of occupation very refreshing and
speaks with warmness about the people in his care and keenness to help them as
much as possible. Apart from the STEADY on! session, Simon has no other knowledge
of falls prevention, but speaks of personal incidents regarding falls, as well as
professional issues.
Stakeholder 8
Having worked with older people for a good number of years as a Review Assessment
and Support Officer, Sandra has a seasoned knowledge about falls and the importance
of falls prevention. She works regularly with older people, often meeting older people
after a fall has occurred, rather than in time to work towards preventing it. Sandra is
able to provide accounts and explanations of how falls can affect not only the older
person, but also their families and witnesses the change in relationship dynamics
170
following a fall. Sandra has experience of completing multi-facetted falls risk
assessments and referral to, usually, the NHS for intervention post fall.
Stakeholder 9
Sally has been in her role as Scheme Manager for over a decade, working with an
emphasis to develop meaningful professional relationships with the older people she
wardens to ensure the most appropriate support is given. She has witnessed the
physical and psychological decline of older people who have fallen, and also lost clients
to falls. This is either through rehoming due to the fall or fatality shortly after the fall.
The facility has a lively social group, supported by Sally, which welcomes external
speakers and activities to their events, coffee mornings in particular.
Stakeholder 10
Similar to Sally, Susan has worked with older people as a Scheme Manager for 25 years
and speaks of appreciating the need to develop worthy relationships with the older
people. The facility is a private complex with a more affluent population than the
surrounding neighbourhood. Susan is happy to co-ordinate visitors to speak to the
residents in the communal area, usually at the residents’ request. Falls or falls
prevention have never been a requested session, nor suggested by the management.
Stakeholder 11
Working to support older people to live independently within their capability in their
own homes, Sarah has worked as a health care practitioner alongside clinical
professionals for almost 10 years. She describes a sentiment of being ‘lumbered’ with
falls prevention because no other organisation will take the lead. Sarah is experienced
171
at both falls assessment and a level of specific intervention, but most frequently comes
into contact with older people once they have already experienced a fall.
172
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