Fall Prevention and Risk Factors among the Elderly in Care Facilities









Table of Contents

Chapter 1: Introduction to the Problem.. 4

Introduction. 4

Problem Statement 5

Rationale and Significance of the Study. 7

Research questions. 7

Definition of terms. 7

Summary. 8

Chapter 2: Literature Review.. 9

Introduction. 9

Best practices in fall prevention. 9

Falls incidences. 11

Risk factors associated to falling. 12

Implication of falls. 13

Effective fall prevention strategies. 14

Falls risk screening. 14

Falls risk assessment 15

Summary. 15

Chapter 3: Methodology. 16

Introduction. 16

Setting. 17

Evaluation methods and tools. 17

Reliability and validity. 18

Integrity of data and data use. 19

Research design. 20

Research methods. 20

Explanation of research methods. 23

Data analysis. 25

Participants. 25

Permissions. 26

Summary. 26

References. 27

Appendices. 33

Appendix A: Permission from Long-term acute care institution. 33

Appendix B: Permission by Western Governors University- IRB.. 34

Chapter 1: Introduction to the Problem


The study will help in identifying the causes or major risk factors among the elderly persons that might predispose them to fall and the common interventions used in the health facilities when dealing with fall-injuries. In the study, the research will involve a sample of male and female individuals that are above 65 years of age in long-term acute care facilities. The participating members shall include people from all educational and socioeconomic strata. It is inclusive of people that have decreased balance; experienced falls in the past or those who feel apprehensive about their chances of falling.  The chosen group will be English speaking to avoid or eliminate the language barrier and the associated bias. However, to avoid any need for special considerations, members will get excluded from the study if they use mobility aids, history of vertigo, chronic ear infection, diagnosed with cognitive impairment and or suffer a medical condition that would hinder them from participating safely

The topic is paramount since falls have gotten reported as an everyday occurrence and is also a potentially grim mortality-problem for old people. By analysis of the various causes and intervention strategies, the weaknesses and strengths of current programs will be evaluated leading to improved approaches. In people exceeding 65 years of age, 3.6% of fall-related hospitalizations almost ultimately lead to the death of the patient (Choi, Lawler, Boenecke, Ponatoski and Zimring, 2011). They are recurrently related to the outcome of injury, fear of falling, social isolation and even when lethal can result in the death of the victim (Sosnoff, Finlayson, McAuley, Morrison, and Motl, 2014). They are also frequently believed to co-occur with two other conditions that are frailty and fractures which have been reported to share risk factors. Fall injuries and hip fractures are significant public health concerns that get associated with considerable cost on healthcare especially in the homes and health facilities for the aged.

Fall prevention studies are important to nursing in the contemporary setting since with the increased life-expectancy the aged population ratio is increasing, and the magnitude of its impact in public health is getting elevated. Falls have been reported to occur at all ages, but the frequency and seriousness of falls-related injuries increase with age (Choi et al., 2011). Risk assessment of the aged persons’ risk for fall and then subsequent implementation of appropriate fall intervention strategies can drastically decrease the rate of falls in the elderly long-term care residents (Frick, Kung, Parrish, and Narrett, 2010). It will minimize the exacerbation of other complications associated to falls reducing the nursing-care burden.

Problem Statement

Problem: Falls qualify as the commonest cause of injuries among the elderly people, and they represent approximately 30% of the injuries that old people of over 65 years’ experience (Pfortmueller et al., 2014). For those that are over 75 years, the rates are higher. 20 to 30% of elderly people who usually fall suffer injuries that reduce their mobility that under certain conditions will eventually increase the risk of premature death (Conroy, 2009). Falls, get not just associated with mortality but also get associated to low quality of life, and a higher likelihood of early admission to long-term acute care facilities. Falls, and resultant injuries among the aged are due to a combination of demographics associated issues and their interaction with their surroundings. It also results to additional social costs; as a result, of hospitalization and long-term acute care admissions (Graham, 2012). Falling has gotten repeatedly associated with psychological problems such as depression and anxiety, social exclusion with increased dependence on social and health care services. It increases healthcare costs on the patients and is a major reason many fall victims live in destituteness.

Background information: One in every three elderly individuals (about 30%), experience a fall more than once in a year (Choi et al., 2011). The risk of falling is higher when other conditions that affect the stability of a patient’s body such as neurological conditions, visual impairment, cognitive problems, or other medical challenges that lead to an alteration in functional ability are present (Lea et al., 2012). The fall rates among institutionalized residents are greater than those among community-dwellers (Kelsey, Procter-Gray, Hannan, and Li, 2012). The use of physical and pharmacological restraints including medications leads to more severe injuries from falls due to attached side effects or interactions. However, interventions are paramount to reducing mortality, morbidity and suffering for the older people and their families. A plethora of intervention strategies targeted for individuals have been indicated to work, but proper monitoring and further evaluation in a long-term acute care facility gets required.

Possible causes: Some frequently enumerated causes include sedative use, mental impairment, lower body-extremity weakness, impaired reflexes, gait in-capabilities and environmental hazards (Albert et al., 2014). Other common deducted causes are presence of a history of falls, wandering behavior among the aged-persons, presence of cognitive impairment and hypertension occurrence (Choi et al., 2011). The associated sedentary life of the elderly elevates occurrence due to weakening posture, and other factors may also encompass a poor vision, vitamin D deficiency and diabetes effects.

Rationale and Significance of the Study

Falls in older people are a grave cause of ill health and subsequent death. It has gotten eluded that one in every three people above the years of 65 and a half over the age of 75 years fall every year (Dollard, Barton, Newbury and Turnbull, 2012). Fall prevalence rates in high-risk persons especially those in home-care and geriatric care settings are overall higher: 10% on a weekly basis, 12% in three months, 20-50% over six months and 35-60% annually (Conroy, 2009). In institutionalized care, the incidence of fall is approximately two falls per bed per year (Haines, Bell and Varghese, 2010), and among individuals 85 years and older 20% of fall associated mortalities occur in residential care settings. It is paramount to evaluate the current scenario in terms of the major risk factors that the aged are exposed to (intrinsic and extrinsic), and the intervention strategies of importance that are used to mitigate the falls in a long term acute care facilities setting. Identifying the older people in the study predisposed to the highest risk of falling aids in maximizing the effectiveness of the proposed intervention strategy.

Research questions

This study will get based on two-research questions

  • What are the major risk factors involved in falls among older people?
  • What is the most effective intervention strategy to prevent falls in long-term acute care facilities?

Definition of terms

Fall– it gets defined as an event that results or leads to a person coming to contact or rest inadvertently on the ground or floor or any other lower level surface, and other than as a resultant of: undergoing a ferocious blow, sudden paralysis, or epileptic seizure (Miake-Lye, Hempel, Ganz and Shekelle, 2013).

Hip protector– a device used to decrease hip fractures in older people (Boye et al., 2013).

Intervention– defined as a therapeutic procedure or treatment method that is designed to cure, eliminate or improve particular medical condition (Heaslop and Salisbury, 2009).

Older people/ elderly/ aged– people above 65 years (Dollard et al., 2012).

Falls risk screening– described as a brief process of estimating an individual’s risk of falling using screening tools (Vind, Andersen, Pedersen, Jorgensen and Schwarz, 2009).

Fall risk assessment– it gets defined as a more detailed process than screening used to enumerate the underlying risk factors of falling and quantifying overall risk (Hempel et al., 2013).


The aged persons especially those who are above 65 years are more prone to falling as compared to the young and in the elderly; ladies have a higher prevalence. As life expectancy exacerbate, so does the menace of fall-incidents that get associated with fall injuries, and the most common being fractures (Hutchinson, Connolly and Lovitt, 2013). The increase in fall-injuries has been linked to the rise in hospital admissions, residential care or institutional settings acute care and communal dwelling homes for the elderly. The rate of falls is at times exacerbated by the occurrence of certain physical and mental health conditions such as weak bones or osteoporosis, dementia, poor vision and cognitive impairment among others. It is, therefore, important to use fall prevention programs that are personal-tailored following an appropriate risk assessment and connecting the intervention approach to identified factors.

Chapter 2: Literature Review


The reported fall numbers among the elderly has continually become a significant public health challenge at a global level (Van Harten-Krouwel, Schuurmans, Emmelot-Vonk and Pel-Littel, 2011). In a study in 2010, in the United States, it was reported that one-third of those aged 65 years and above experienced a fall annually and rising to above 50% for those aged 85 years and above (Boye et al., 2013). In a higher prevalence study, in the Netherlands, it was deduced to average at 51% in a period of study of over 10 months among the community-dwelling older population. The causes (risk factors) are linked to falls always interacting to influence the victim’s health in a multi-factorial approach. Falls may increase the risk of complications, including the probability of developing a phobia for a fall or curtailing of confidence in walking (Sosnoff et al., 2014).

Best Practices in Fall Prevention

In general, the best practice for falls prevention includes a number of factorials that comprise initially implementing standard fall strategies in areas where the elderly occupy or get accommodated when in a care-setting. On the identification of fall risks, interventions targeting the specific risk factors are then be implemented, putting in injury prevention mechanism for those prone to falling (Lovarini and Bawden, 2010). Fall prevention trials have executed interventions targeting modifiable risk factors for falls in older people who have got poised as being at a higher risk of falling with some exhibiting success in falls rate reduction. However, due to the enormous number of older people considered to be at the risk of falling in hospital and personalized home care, application of broad approaches can be costly to implement and maintain (Walker, Porock and Timmons, 2011).

The more cost-effective model of intervention has gotten reported to be focusing directly on the prevention of injurious falls among the older people at risk of exposure to fall-related injury, other than general fall prevention (Campbell and Robertson, 2013). In most healthcare systems globally, the expanse of resources available to provide treatment and rehabilitation for the injured are insufficient for all people’s programs (Hutchinson et al., 2013). The responsibility of health care providers includes deciding on how they can facilitate improvement in health outcomes with finite resources while selecting the most effective intervention that can get afforded in various institutions. An economic evaluation (cost effective intervention analysis) compares both the costs and health outcomes for the program and the alternative options available (Mackenzie, Clemson and Roberts, 2013). The health issues from a fall prevention intervention can get calculated in terms of natural units like falls prevented, fractures prevented, deaths prevented and survival. Survival can get given as ‘life years saved’ (LYS) or as multi-dimensional health results that include both survival and life quality in a single composite measure such as quality-adjusted life years (QALYs) (Frick et al., 2010).

Multifactorial approach has gotten reported as the most effective when implemented in fall intervention models (Graham, 2012). However, particular personal interventions, for example, hip protectors, supplements of calcium or pharmacist review of medications prevent fractures thus reducing the risk of fall in some people. Provision of vitamin D together with calcium mineral supplement to the elderly (those who have low-blood levels of vitamin D) acts like a single-intervention strategy to prevent falls incidents (Campbell and Robertson, 2013). A number of strategies effective in falls reduction have gotten known. In multi-dimensional approach, there are a plethora of multidisciplinary team interventions (Walker et al., 2011), comprehensive geriatric assessment and may also involve staff education (institutionalized care). Other activities also include balance exercises (Merom et al., 2013), environmental adaptations/ adjustments with post-fall management. In particular intervention approach the encompassed actions include medication review, use of hip-protectors and use of vitamin D supplementation.

Falls Incidences

Falls have immense consequences for the aged quality of life, morbidity and death as well the incurred costs in healthcare (Dollard et al., 2012). They get associated with a plethora of factors such as environmental obstacles, delirium, prescribed drugs, dementia and also incontinence (Fischer et al., 2014). In elderly-home care, falls study data indicate that bedside is the most common point for falls to occur with a closer mention of the bathroom while taking a shower (Haines et al., 2010). The incidence rate of fall gets spread across the age groups, but with increasing age, the prevalence also spikes. A higher ratio of falls is also not witnessed, and prevention mechanisms are, in a way, in-abated due to causal model retribution. In terms of type, there is no significant difference between those experienced by older men or women but the incidental rate for women is higher in institutionalized old populations (23.6%) as compared to men (17.5%) (Van Harten-Krouwel et al., 2011).

The femur fracture has gotten identified as a significant fall injury in follow-up care admissions (Pfortmueller et al., 2014). The proportion of falls that result in fractures is low, but the absolute number of the elderly people that suffer from fractures is enormous and has been considered to increase the costs of health care systems globally. About 10% of the falls result in serious injuries, and 5% of these are fractures, and most age-related of these are spine, pelvis, wrist, hip, and femur (Kelsey et al., 2012). Among the aged, the hip fracture is more taunting and is higher in residential settings with occurrences of approximately ten percent persons in the years reported.

Risk Factors Associated with Falling

Among the residential care and institutional care patients especially for the aged, a plethora of risk factors that predispose the victims to falls does exist. Some commonly mentioned factors include sedative use, mental impairment, lower body-extremity weakness, impaired reflexes, gait in-capabilities and environmental hazards (Albert et al., 2014). Intrinsic factors are those related to the individual’s personality in terms of behavioral characteristics or health when deliberated on from the point of medical or health well-being. Extrinsic factors are those defined as a consequence of a person’s environmental influence or via interaction with the surroundings at times out of a person’s control (Ryan-Wenger and Dufek, 2013). In studies, some of the most likely causal phenomena have gotten identified, and these were the most involved in the matrix of falls. Fall risk factors in aged nursing facilities include personal risk factors, and some are the aging population; compromised health condition; history of previous falls; wandering/ mobile behavior and cognitive disability/ impairment (Choi et al., 2011).

Another factor exacerbating falls include maximal drop in postprandial (after feeding) systolic blood pressure of at least 20mm Hg and in diastolic blood pressure of at least 10mm Hg within three minutes of standing. Diminished performance of activities of daily living or being sedentary, deteriorated lower extremity strength/ power or balance, with the use of a mobility aid or unsteady gait, and poor vision are among crucial promoters to fall occurrences. When medication gets involved: certain prescribed medication such as the use of antidepressant medications and multiple drugs consumption are critical in resulting to falls, and can be a psychotropic medication withdrawal’s side effect. Diabetes mellitus comorbidity, gender (mostly elderly women) and vitamin D deficiency are all paramount personal risk factors. Some of the identified environmental risk factors constitute unsupported relocation to different locations, environmental hazards to the victim and use of poor walking aids (Choi et al., 2011).

Implication of Falls

The hip joint and the thigh area are the most commonly injured areas in both men and women sustaining falls. Femur fractures are a common feature together with head injuries (especially for men) which has contributed to the increased research on the mechanisms to prevent these frequent fall injuries (Chari, McRae, Varghese, Ferrar and Haines, 2013). Hip fractures consist of one of the most contributory reasons to hospital admissions of the aged, with 91% caused by falls. The fractures impact heavily on the society; as a result, of increased casualties and morbidity, an increased burden on other family members and caregivers, with a decreased independence in terms of mobility and self-care (Wolf et al., 2013). Among these effects, one paramount implication is the increased cost due to the rehabilitation of the patient and increased hospital admissions and institutionalization. Wrist fractures are also a widely reported instance when individuals putout their limbs to break the fall.

Fall-related fractures get usually associated with a substantial human effort and financial cost, and this tends to be a bigger burden when it is the culmination of old age that is exorbitant on even the social welfare (Chari et al., 2013). It may extend the duration of admission with increased diagnostic, surgical procedures, and in the institutionalized individuals there is the caregiver stress with fear of any eventual litigation among clinical and administrative workers in the homes for the elderly (Ryan-Wenger and Dufek, 2013). On the occurrence of falls, the post-fall syndrome has been associated with low demeanor, social withdrawal, loneliness and confusion even with the absence of injury (Miake-Lye et al., 2013). After the fall, lying on the floor for long periods among the elderly has been linked to effects such as dehydration, pneumonia, hypothermia and even death in about half of the victims (Dollard et al., 2012).

Effective Fall Prevention Strategies

While compounding or interpreting the subgroup analyses, there were unabated indications that multidisciplinary team interventions and comprehensive geriatric assessments were the most effective in reducing the number of fallers (Miake-Lye et al., 2013). Nurse–led interventions that excluded exercise in the program were not as effective as compared to those where both physical exercises that promoted mobility and mental activity that promoted alertness got included (Stubbs, 2011). From a study, it has been reported that low-intensity interventions may have less impact than the usual care which negates their functionality in terms of desired impact with diminished performance compared to control subjects (Lea et al., 2012). Educating the elderly has also gotten reported to be an effective intervention method (Lovarini and Bawden, 2010). For interventions to be effective, there are two necessary steps to get undertaken by the caregiver in either residential care or old age home care where the conditions of the aged get rated in terms of severity. They comprise falls risk screening and falls risk assessment.

Falls Risk Screening

It involves a brief process of estimating an individual’s risk of falling and classifying them as either moderate or high-risk character (Vind et al., 2009). Positive screening of particular screen items provides essential information on intervention strategies. The efficiency when undertaking screening is highly dependent on the evaluator’s intuition and exposure to characteristic patients highly predisposed to falls (Stubbs, 2011). One central falls risk screen that is paramount in routine care is the individual’s falls history. Examples of these screens include Timed Up and Go which is performance-based, as well as Modified GetUp and Go tests.

Falls Risk Assessment

It defines a significant procedure applied in enumeration of the associated risk factors for falling and classifying individuals into lowly predisposed and high-risk groups (Hempel et al., 2013). Specific falls risk assessments identify falls risk factors like gait and equilibrium, exercise capacity, and prescription drugs use. The matrix involved in causing an individual’s fall becomes characterized from interaction of both intrinsic and extrinsic factors, and this gets used for the person exceeding threshold of a falls screening tool or has suffered a fall. The validity of the obtained data is dependent on validation of the assessment tool and mostly it gets adapted for specific conditions. An example of an assessment tool is STRATIFY and Peninsula Health Falls Risk Assessment Tool (FRAT) that includes three sections: falls risk status, risk factors exposed to and the action plan or intervention strategy (Mackenzie et al., 2013). Special considerations when conducting the assessment include cognitive impairment, rural and remote settings, indigenous, culturally and linguistically diverse groups and limited mobility aspect.


The more elderly population especially above 65 years is more prone to falls and fractures that are accompanied by fractures (Pfortmueller et al., 2014). The probability of falls occurring becomes determined and exacerbated by the interaction among the various risk factors that include the intrinsic, extrinsic and exposure to risk (from the two main factors interacting) (Albert et al., 2014). Within the elderly people, a strategic approach to falls and fracture prevention has three levels that include first identification of higher risk groups within more aged people. Then, a detailed assessment of high-risk older people that identifies the different risk factors for falls or the resultant fractures is done before finally applying the intervention strategy to minimize the known risk factors (Hempel et al., 2013). The multi-factorial approach in intervention is greatly successful in the reduction of fall risk factors.



Chapter 3: Methodology


The study will apply a qualitative methodology as the approach of analyzing fall prevention in long-term acute care set ups. The qualitative research is a scientific method that seeks to provide a comprehension of the experiences by the patients and health care workers in a subjective aspect that cannot be described in numerical form (Patton and Cochran, 2007). Qualitative methodology is adequate in determining intangible factors in causing falls, offering descriptions of how participants perceive, and experience falls (Vind et al., 2009). In the analysis part of the study, data will be collected from caregivers in the long-term care centers, which will provide qualitative information to comprehend strategies adopted to take care of the issues raised by the elderly (Choi et al., 2011).  The part of obtaining intervention data within the study will also make provision for the immediate feedback, which would allow for efficient fall prevention data. Additionally, areas with gaping concerns where the aged are more exposed to fall occurrence that result to lethal injuries will also get identified. The feedback represents great value in terms of getting success in the program, also resulting in better interpretation of the outcomes of the study.


The objective of the research is to scrutinize the characteristics and scope of falls and the associated fall injuries in long-term acute care settings. Visits to this setup will be made to enumerate the most possible causes (or risk factors) of falls among the aged persons and the efficacy of any adopted fall prevention and management programs, in the care facilities.

Evaluation Methods and Tools

The evaluation strategy will involve qualitative research model that will include the approaches of personal observation, with an unstructured questioning (open ended) of both the elderly and their respective caregivers, which will then provide a basis for subjective human interpretation (Mackenzie et al., 2013). In the formative evaluation, there will be an assessment for the needs of the study and how they will get achieved within the context of the research work (Trochim, 2008). One paramount aspect of the evaluation will be to identify the most acceptable definition of the falling problem and its scope within a long term acute care setting. To obtain the study definition of the issue of falls, conceptualizing methods that include literature search on the previous research data will be significant (Lovarini and Bawden, 2010). Evaluation tools that will be essential in understanding and presenting the issue of falls will include the utilization of focus groups that will entail discussions among the elderly and their caregivers on the issues contributing to falls. Discussions will also include the exacerbating factors that promote fall occurrence within the care institutions.

The scope of the falls-problem (that is how significant it is) will get evaluated via personal interviews conducted by the researcher on the elderly persons within long-term acute care setups, during the duration of the study (Smith, 2013). Questions will be used to determine the participants’ current daily activities, with an evaluation being made on the history or previous experience of falling (Chari et al., 2013). The effects of falls (particularly incidences of injuries and the type of frequent injuries) and possible medical care will also get determined from caregivers. The elderly person’s view on safety with regards to fall occurrences will get evaluated and the most appropriate remedies necessary pointed out. Interview meetings will also aid in evaluating the available intervention strategies among caregivers and the efficiency in relevance to their application within the care setups.

Reliability and Validity

The most significant evaluation methods that are to get used within the study include personal observation, open-ended questioning during patient and caregiver interviews, detailed and technical literature search and the discussions to get held within focus groups. Physical observation will enable to capture those details that would escape capture in discussions during interviews such as safety precaution measures installed to avoid falls e.g. less steep stairs and holding bars. Open-ended questioning is the most preferred tool of information collection especially when dealing with the elderly individuals since it will give non-restricted responses; the participants will have free-will to structure their answer as they wish and from their own understanding (Chari et al., 2013). Literature searches in clinical databases are to provide scientific evidence and credible data that will guide and aid in structuring the study. Within focus groups, the information on personal experiences about falling will get freely shared.

For each question, the results will get interpreted independently apart from the questions that will have been asked at the period of screening as the elimination tool for study subjects that do not meet participants’ acceptance criterion. The data will get recorded and analyzed using various techniques. A method of recording data by most respondents (the elderly and the health care givers) will involve recording responses via narratives. Narratives will help in the review of the research questions and in understanding how participants describe their experiences (Dollard et al., 2012). The initial data interpretation procedure will involve an analysis method of coding, which is a cardinal technique that shall serve to create a conceptual framework for the purpose of developing meaning from the narratives by respondents (Patton and Cochran, 2007). The method will get applied in standardizing the narrative descriptive statistic from the respondents.

Integrity of Data and Data Use

Participation in the research-work will be voluntary, and members will participate in interviews and audio taping and may withdraw at any point without being penalized for non-participation. Any health related information gathered from the participants in the study will remain under confidential use of the researcher without any form of disclosure to a third party. All reasonable endeavors will be in place to ensure identity protection of the participants, in the sharing of data with liable persons to support the research work. Before any focus group discussion takes place, informed consent will be given to participants or their legal guardians without loss of their rights.

All participants’ records for this research project will get stored in confidentiality, and only the single researcher will see the individual records when evaluating the health condition of the participant and other demographic traits. All data collected will get intended to be only used on this research study without future unapproved applications. If, for any reasons, case studies are to get conducted or on any discussion of this project, the participant’s identity will get used anonymously and the data kept integrated with only divulging of necessary figures.

Research Design

A cross-sectional study design will get employed in the study. It is usually carried out over a short period, and data collected are individual characteristics encompassing risk factors and associated outcomes (falls) (Levin, 2006). Fifty-three participants who reside in a long-term acute care facility will get recruited for the study both male and female (considering inclusion criterion). Identification of participants will be through purposive sampling among potential risk-fallers by health workers.

Research Methods

The commonly utilized qualitative research methods include: literature searches, direct talking with study members, telephone surveys, internet or online surveys, physical mail surveys, email surveys, personal interviews and use of focus groups especially in patient groupings (Shuttleworth, 2014). Data in the current research will get collected using some of the methods identified above that are most relevant to the conditions of the study and statistics expected to get derived. Data collection will, hence, get done via interviews, un-structured questionnaires, observation (of the first person), literature searches and focus group discussions within the long term acute care facilities. The two groups of participants that will get involved will be elderly patients and the caregivers in the selected facilities.

Interviews will get used to collect data pertaining to the fall risk factors (or most probable causes) that old people are exposed and predisposed to within the long term acute care facility centres. The available fall prevention strategies within the care setting will get enumerated, and the effectiveness in mitigating falls determined, after which best alternatives will also get inferred from both the aged person’s and caregiver perspective. There will be interviewing of the aged participants and the care giving experts; it will be paramount in helping to gain a direct research focus during discussions on specific parameters. Before the interview gets conducted, the participants will be contacted through a telephone call and email message for the purpose of scheduling interview appointments. The obtaining of consent before the interview is always crucial in order to ensure that the interviewee is mentally astute and responsive and in order to avoid biased results (Valenzuela and Shrivastava, 2010).

Unstructured questionnaires that encompass the use of open-ended questions will also get used. Two questionnaires will get administered in the study with one targeting the elderly, which will determine the falls history, medical care obtained and the effects (mostly in terms of injuries). The other will target the caregivers to provide the falls-incidence rate among the elderly and the interventions given, along with associated success in preventing recurrence of falls. The research tools will get offered to the participants, acting as a basis to supplement the data collected from the interviewing. Questionnaires will provide a written description of the requested data response, which shall provide more specificity than interviews and enable collection of high reliable amounts of data due to the guidance provided by each question. With the guidance, there is easy interpretation by the participant in the study (Olsen and St. George, 2004).

In addition to carrying out interviews and administering of questionnaires, observation by the researcher will also form a critical data collection method in the current research. Visitations to the long term acute care settings will get undertaken during which there will be an examination of the expected risk factors that cause falls among the elderly in residential areas. It will also look at the fall prevention, and management approaches present, with the attached efficacy of these undertakings, as well. The observed factors and intervention strategies put in place will be enumerated to act as part of the descriptive statistics.

Research on existing literature that contains previously reported data on falls occurrence and prevention will get used to guide the research on the existing gaps within the body of knowledge that reduce the efficacy with which falls intervention programs operate (Harvard, 2007). In this regard, a comprehensive search on existing literature will be limited to data that got reported in studies whose participants were only adults over the age years of 65 and those that had a residence in particular setups. The research evidence will get obtained by conducting a keyword search in medical databases including online published journals, books, state document records and other resourceful peer-reviewed documentation within the internet platform. Through filtering of the relevant material, a collective research data will get compiled, which will enable the understanding and reporting of effective fall prevention strategies (Boye et al., 2013).

Focus group will get initially used to represent a preliminary research tool or methodology to capture the participants’ ideas and attitudes in the study context (Shuttleworth, 2014). A collective perspective will get enumerated within the auspices of group discussions, which will encourage open conveyance of the understanding of falls causative risks among the elderly and the best practices to effectively reduce or eliminate them all together. The effects of comorbid conditions such as cognitive impairment, hypertension, and poor gait and vision will also get discussed to comprehend the general effect dissipated within the population sample. The acceptance and efficacy of provided medical care among the study’s members will also get described.

Explanation of Research Methods

Each method applied within the context of the study should be capable of ensuring the achievement of the research objectives. The data collected by the adopted methods shall be adequate to infer to the research questions that the study gets based. Qualitative-research interviews will describe the comprehensive meanings of the central theme in the subject (Valenzuela and Shrivastava, 2010). It will cover both the factual level and the intricate description of fall experiences by the elderly patients and the medical caregivers, in the acute care setting. It is paramount since it shall provide an in-depth understanding of the research subject from a personal feedback or two-way discussion platform.

The questionnaire study tool will be crucial since it is part of the process designed to result in the generation of data narratives from the participants. It shall cover the defined research questions of interest in the study (Olsen and St. George, 2004). Pilot testing of the of the questionnaire will get done through administration to a small group of individuals (about two persons) from the acceptable target group, which will then get followed up to obtain feedback on the issues (such as the wording and whether the respondents comprehend the questions). It will also look at the efficacy of the questionnaire (such as the ability to be as short as possible, thereby, avoiding barriers to effective communication). The administered questionnaire will hence be a standard practice tool that generates valid responses from targeted elderly persons and caregivers. The questions shall be open-ended (the unrestricted type), and hence modeled to elicit free responses that allow respondents to dissipate more valid data through expression of their opinion freely, on issues raised by research questions (Lea et al., 2012). Questionnaires will be important in deducting research questions and comprehending specificity of expected outcomes in the study.

Studies engage observation, which is a qualitative measure. The frequency of an outcome (or exposure occurrence) dependent on the study design shall get measured, undergo estimation or get visualized using an observational study (Jepsen, Johnsen, Gillman and Sorensen, 2004). Although parameters such as body condition and extrinsic factors will not be quantifiable when observing, descriptive statistics will be used to code such relevant information. Measures such as risks, rates, prevalence and odds shall get used to describe the frequency of an outcome such as the case in falls occurrence. It should aid in the description of the association between exposures (risk factors) and the outcome (fall occurrence or prevention efficacy) providing the basis for drawing of the study’s conclusions descriptively (Conroy, 2009). Observation shall help in deduction of the parameters not covered by the interviews and questionnaire but still critical in the analysis of risks and interventions’ efficiency.

Peer reviewed information forms the basis for a valid collection of data with minimized bias and inconsistencies when performing a literature search on the topic of interest. The results will get used in carrying out comparative analysis to the obtained descriptive information in the current study, aiding to understand and interpret the falls data on risk factors among the elderly and the most effective intervention approach. In order to improve the accuracy of searched content while reducing ambiguity, the research topic specificity shall be critical particularly on the type of participants (elderly), the medical condition or situation being searched (falls) and the type of intervention or clinical strategy under investigation (Harvard, 2007). The literature search shall aid in presenting the gap in research on risk factors associated to falls and the subsequent intervention approaches whose effectiveness will get studied within the current study.

The collective approach in discussions (within focus groups) will be crucial since it shall provide an avenue to suggest the testing of novel approaches in mitigation against falls while also discovering new falls-victims’ concerns, in terms of unrecognized risk factors (Crossman, 2012). The recorded responses will aid in collecting data that finds significance in the drawing of pertinent conclusions while making informed recommendations to involved parties.

Data Analysis

After collection of all the data, it will be analyzed thematically using Nvivo software supplemented by manual analysis. The coded data from narratives will be entered into the analysis software to get the descriptive statistic variables. In calculations during analysis, Microsoft Excel spreadsheets will be used to determine descriptive measures such as mean response and ratios such as in injury prevalence or fall occurrences, measures of dispersions among other deductible parameters (depending on obtained data set).


Ten participants (patients) are to get identified through purposive sampling as potential risk fallers by health workers in a long-term acute care facility, from which permission has gotten sought. Caregivers to participate in the study will also be from the same organization. The necessity for human participants is to obtain first-hand data from them; hence, enabling the making of conclusive remarks in the study (Stubbs, 2011). The demographic criterion of inclusion in the research will target male and female participants over 65 years of age (the elderly or aged persons). In terms of language, the intended trait is that the participant has to be English speaking and capable of following three-step instructions, is alert and has an orientation to person, place, and time. The members of the study will also be representative of the persons from all educational levels and socioeconomic strata in the society. The inclusion criteria also encompass people that have a decreased balance, those who have experienced falls in the past and those who feel apprehensive about their chances of falling.

The exclusion criterion for the study will encompass participants that use mobility aids, those that have a medical history of vertigo, chronic ear infection, diagnosed with cognitive/ mental impairment and sufferers of a medical condition that can hinder their participating safely in the study. No participants included in the study will be related to the researcher (this will reduce bias of obtained data).


Permission has gotten granted after being sought for the current research, from the institution where the study will take place (long-term acute care setting). Additionally, an application for getting approval of the research project has been made to the university institutional review board.


The qualitative-research methodology will get used in the study. The study will also benefit from the application of descriptive statistics data presentation (Patton and Cochran, 2007). Purposive sampling will be done to identify participants. With the current methodology, it can be noted that subjective-research methods form the basis for enumerating data among the elderly persons (major risk factors) and the health care givers (medical care and intervention strategies).



Albert, S.M., King, J., Boudreau, R., Prasad, T., Chyongchiou J., L., and Newman, A.B. (2014).

Primary Prevention of Falls: Effectiveness of a Statewide Program. American Journal Of Public Health104(5), 77-84.

Boye, N., Van Lieshout, E., Van Beeck, E., Hartholt, K., Van Der Cammen, T. and Patka, P.

(2013). The impact of falls in the elderly. Trauma15(1), 29-35.

Campbell, A., and Robertson, M. (2013). Fall Prevention: Single or Multiple Interventions?

Single Interventions for Fall Prevention. Journal Of The American Geriatrics Society61(2), 281-284.

Chari, S., McRae, P., Varghese, P., Ferrar, K. and Haines T.P. (2013). Predictors of fracture from

falls reported in hospital and residential care facilities: a cross-sectional study. BMJ Open, 2013(3), 1-8.

Choi, Y., Lawler, E., Boenecke, C.A., Ponatoski, E.R. and Zimring, C.M. (2011). Developing a

multi-systemic fall prevention model, incorporating the physical environment, the care process and technology: a systematic review. Journal of Advanced Nursing, 67(12), 2501-2524.

Conroy, S.P. (2009, February). Preventing Falls in Older People. Retrieved May 22, 2014, from


Crossman, A. (2012). Focus groups. Retrieved June 30, 2014, from http://sociology.about.com/od/Research-Methods/a/Focus-Groups.htm

Dollard, J., Barton, C., Newbury, J. and Turnbull, D. (2012). Falls in old age: a threat to

identity. Journal of Clinical Nursing21(18), 2617-2625.

Fischer, B.L., Hoyt, W.T., Maucieri, L., Kind, A.J., Gunter-Hunt, G., Chervenka-Swader, T., and

… Gleason, C. E. (2014). Performance-based assessment of falls risk in older veterans with executive dysfunction. Journal Of Rehabilitation Research & Development,51(2), 263-274.

Frick, K.D., Kung, J.Y., Parrish, J.M. and Narrett, M.J. (2010). Evaluating the Cost-

Effectiveness of Fall Prevention Programs that Reduce Fall-Related Hip Fractures in Older Adults. Journal of the American Geriatrics Society58(1), 136-141.

Graham, B.C. (2012). Examining Evidence-Based Interventions to Prevent Inpatient

Falls. MEDSURG Nursing21(5), 267-270.

Haines, T.P., Bell, R.R. and Varghese, P.N. (2010). Pragmatic, Cluster Randomized Trial of a

Policy to Introduce Low-Low Beds to Hospital Wards for the Prevention of Falls and Fall Injuries. Journal of the American Geriatrics Society58(3), 435-441.

Harvard, L. (2007). How to conduct an effective and valid literature search. Nursing Times,         103(45), 32-33.

Heaslop, M. and Salisbury, J. (2009). Preventing Falls and Harm From Falls in Older People:

Best Practice Guidelines for Australian Residential Aged Care Facilities. Retrieved May 22, 2014, from http://www.safetyandquality.gov.au/wp-content/uploads/2012/01/Guidelines-RACF.pdf

Hempel, S., Newberry, S., Wang, Z., Booth, M., Shanman, R., Johnsen, B., and… Ganz, D.A.

(2013). Hospital Fall Prevention: A Systematic Review of Implementation, Components, Adherence, and Effectiveness. Journal Of The American Geriatrics Society, 61(4), 483-494.

Hutchinson, I., Connolly, M., and Lovitt, L. (2013). Falls Prevention is Everyone’s Business.

Falls Links, 8(4), 1-18.

Jepsen, P., Johnsen, S.P. Gillman, M.W. and Sorensen H.T. (2004). Interpretation of         observational studies. Education in Heart, 90, 956-960.

Kelsey, J.L., Procter-Gray, E., Hannan, M.T. and Li, W. (2012). Heterogeneity of Falls among

Older Adults: Implications for Public Health Prevention. American Journal of Public Health102(11), 2149-2156.

Lea, E., Andrews, S., Hill, K., Haines, T., Nitz, J., Haralambous, B., and … Robinson, A. (2012).

Beyond the ‘tick and flick’: facilitating best practice falls prevention through an action research approach. Journal of Clinical Nursing21(13/14), 1896-1905.

Levin, K. A. (2006). Study design III: Cross-sectional studies. Evidence-Based Dentistry 7, 24     25. doi:10.1038/sj.ebd.6400375

Lovarini, M. and Bawden, J. (2010). Falls prevention education delivered via digital video disc

results in greater confidence and motivation to engage in falls prevention strategies by hospitalised older people when compared with education delivered in written format. Australian Occupational Therapy Journal57(5), 351-352.

Mackenzie, L., Clemson, L. and Roberts, C. (2013). Occupational therapists partnering with

general practitioners to prevent falls: Seizing opportunities in primary health care. Australian Occupational Therapy Journal60(1), 66-70.

Merom, D., Cumming, R., Mathieu, E., Anstey, K.J., Rissel, C., Simpson, J.M., and … Lord, S.R.

(2013). Can social dancing prevent falls in older adults? a protocol of the Dance, Aging, Cognition, Economics (DAnCE) fall prevention randomised controlled trial. BMC Public Health13(1), 1-9.

Miake-Lye, I.M., Hempel, S., Ganz, D.A., and Shekelle, P.G. (2013). Inpatient Fall Prevention

Programs as a Patient Safety Strategy. Annals of Internal Medicine158, 390-396.

Olsen, C. and St. George, D.M.M. (2004). Cross-Sectional Study Design and Data Analysis.        Retrieved June 30, 2014, from                http://www.collegeboard.com/prod_downloads/yes/4297_MODULE_05.pdf

Patton, M.Q. and Cochran, M. (2007). A Guide to Using Qualitative Research Methodology.       Retrieved June 30, 2014, from                http://fieldresearch.msf.org/msf/bitstream/10144/84230/1/Qualitative%20research%20m         thodology.pdf

Pfortmueller, C.A., Kunz, M., Lindner, G., Zisakis, A., Puig, S., and Exadaktylos, A.K. (2014).

Fall-Related Emergency Department Admission: Fall Environment and Settings and Related Injury Patterns in 6357 Patients with Special Emphasis on the Elderly. The Scientific World Journal, 2014(2014), 1-6.

Ryan-Wenger, N.A. and Dufek, J.S. (2013). An interdisciplinary momentary confluence of

events model to explain, minimize, and prevent pediatric patient falls and fall-related injuries. Journal for Specialists in Pediatric Nursing18(1), 4-12.

Shuttleworth, M. (2014). Research methods. Retrieved June 30, 2014, from                       http://www.statpac.com/surveys/research-methods.htm

Smith, S. (2013, January 14). Survey Questions 101: Do You Make any of These 7 Question        Writing Mistakes? Retrieved June 30, 2014, from http://www.qualtrics.com/blog/writing                survey-questions/

Sosnoff, J., Finlayson, M., McAuley, E., Morrison, S. and Motl, R. (2014). Home-based exercise

program and fall-risk reduction in older adults with multiple sclerosis: phase 1 randomized controlled trial. Clinical Rehabilitation28(3), 254-263.

Stubbs, B.B. (2011). Falls in older adult psychiatric patients: equipping nurses with knowledge

to make a difference. Journal of Psychiatric & Mental Health Nursing18(5), 457-462.

Trochim, W.M.K. (2008). Research methods knowledge base: Introduction to evaluation.               Retrieved June 30, 2014, from http://www.socialresearchmethods.net/kb/intreval.php

Valenzuela, D. and Shrivastava, P. (2010). Interview as a Method for Qualitative Research.                      Retrieved June 30, 2014, from           http://www.public.asu.edu/~kroel/www500/Interview%20Fri.pdf

Van Harten-Krouwel, D., Schuurmans, M., Emmelot-Vonk, M. and Pel-Littel, R. (2011).

Development and feasibility of falls prevention advice. Journal of Clinical Nursing20(19/20), 2761-2776.

Vind, A.B., Andersen, H.E., Pedersen, K.D., Jorgensen, T. and Schwarz, P. (2009). An

Outpatient Multifactorial Falls Prevention Intervention Does Not Reduce Falls in High-Risk Elderly Danes. Journal of the American Geriatrics Society57(6), 971-977.

Walker, W., Porock, D. and Timmons, S. (2011). The importance of identity in falls

prevention. Nursing Older People23(2), 21-26.

Wolf, L., Costantinou, E., Limbaugh, C., Rensing, K., Gabbart, P. and Matt, P. (2013). Fall

Prevention for Inpatient Oncology Using Lean and Rapid Improvement Event Techniques. Health Environments Research & Design Journal (HERD)7(1), 85-101.








Appendix A: Permission from Long-term acute care institution

Appendix B: Permission by Western Governors University- IRB