Education interventions for health professionals on falls prevention in health care settings: a 10-year scoping review

The population of interest was health professionals who had received education related to falls prevention. The concept of interest was staff education on falls prevention, and the context of interest was any hospital or healthcare setting. Healthcare settings were defined as acute or sub-acute hospitals, residential aged care facilities, rehabilitation facilities, or long-term care facilities. Falls prevention education interventions to health professionals in the community were excluded. To be included, articles needed to be peer-reviewed and in the English language. Included articles needed to describe primary research of any design (quantitative, qualitative and mixed methods), such as a cluster randomised controlled trial, quality improvement project, prospective cohort studies, pre-post and repeated measure designs, and quasi experimental studies. They needed to investigate falls prevention interventions including a health professions education component, as either a single or part of a multifactorial set of interventions. Our intent was to review interventions from countries with similar pedagogical approaches (i.e. Australia, New Zealand, Canada, the United States of America, or the United Kingdom), with student-centred classes and active participation in the learning and teaching process [41]. The articles had to be accessible as full text, and published between January 2008 and May 2019. Exclusions were websites, handouts or other types of passive educational materials, book chapters and literature reviews.

Additional file 3 outlines the study characteristics including the authors, year published, study design and country in which the study was conducted. The majority of the studies were from the USA (n = 24), followed by Australia (n = 8), Canada (n = 3), Germany (n = 2), and the United Kingdom (n = 2).

Where study design was explicitly reported, seven reported the design as a randomised controlled trial [43‐48]. Ten studies reported their design to be a pre-post study [49‐58], one of these was reported as quasi-experimental [56], and six were cohort studies [51‐55, 58]. One study was described as a quasi-experimental, pre-test/ post-test, pilot cohort [59]. Ten papers reported that their project was a quality improvement or implementation project, often advising that it was evidence based [46, 60‐68]. Other study design descriptions included a multi-strategy interdisciplinary program implementation [69], education intervention [70], translational research intervention [71], or team training in a simulation environment [72].

These elements are outlined in Additional file 4, which include the learning environment, methods of recruitment for the teachers, details of teachers’ experience in education and falls prevention, and whether an evaluation was planned.

For the majority of studies, the rationale for conducting education programs was related to the high rates of falls in hospitals and residential aged care, particularly for those over 65 years of age. Many studies described the consequences associated with falls, including high morbidity and mortality, and associated high economic costs. Researchers noted a lack of healthcare professional knowledge, awareness and skills for implementing fall prevention strategies. Studies reported a need for educationally sound and evidence-based programs that engaged multiple professions in interactive learning and clinically relevant problem solving to achieve high quality patient-centred care.

The purpose of education interventions was primarily described as increasing health professionals’ knowledge, attitudes, skills and behaviour related to falls prevention, and determine whether health professions training had an effect on falls and injury rates. Some studies also reported aiming to improve interprofessional collaboration, communication and teamwork in managing falls. Most studies highlighted the importance of promoting adherence to current best practice falls prevention strategies. They also noted the value of ensuring that the safety education curriculum developed was evidence based.

Over two-thirds (n = 23) of the studies were conducted in a hospital. Nine were in residential aged care facilities, and three studies were conducted in a combined setting. The majority of studies were conducted ‘in house’ though the actual learning environment was not stated. A small number were conducted on wards, in classrooms, or in simulation centres.

Table 1 outlines the reported resources used to deliver the education. Most studies (n = 36) outlined the resources required to deliver the education program. In studies where this was not explicitly described, ‘didactic learning materials’ or ‘practical workshop resources’ were reported [44, 45, 69]. Some identified various support resources, brochures, or handouts, summarising the session and key learning points. One study described supplying a pack incorporating information from international best practice guidelines [58]. Another sent a support package to participants before the education intervention that included a copy of the presentation slides, reference to further readings, and a DVD of the assessment procedures to be covered [47]. One study provided a fall bundle toolkit that included a patient communication board, patient and family teaching materials, and related forms [78]. Of those studies that employed video, one video was a demonstration of an intervention [71], another study used video conferencing facilities to deliver falls prevention education to clinicians [75].

A range of facilities across the studies were used to deliver the training. These included seminar rooms, tutorial rooms, and training centres.

The education programs were taught by a variety of educators, although it was not always clear who delivered the intervention. Around one-quarter of studies utilised nursing staff, who often had some expertise in falls prevention [46, 49, 56, 58‐60, 70, 71, 77, 78, 80]. Other studies employed an interprofessional team, who were usually nominated based on their knowledge of falls prevention, commitment to patient safety or clinical skills [53, 55, 61, 63, 65, 75, 79, 81, 82]. One study reported employing a local expert in the field who had previously published in the area of falls prevention [47]. Four studies reported using trained interventionists to deliver the education, including change agents and falls ‘champions’ [44, 45, 71, 79]. Research team members (including project representatives) were the educators in around one-quarter [43, 46, 48, 51, 52, 54, 64, 68, 69, 76]. Geriatrician clinical educators were the educators in two studies [67, 73], and where the study was carried out in a simulation centre, the simulation centre staff were the educators [60, 72]. Two studies involved self-directed learning [50, 74] and one study did not state who the educator was [62].

Uni-professional education programs were usually delivered to nursing staff, though three studies delivered education to medical staff or medical students [52, 69, 83]. One study reported interprofessional education to nursing and allied health staff, while junior doctors attended a separate session with greater emphasis on diagnosis and treatment of underlying conditions, run by a senior geriatrician [59]. Some studies stated that education was to all employees, or care facility staff but did not state whether they were clinical or non-clinical. Many studies reported educating all clinical staff involved in the care of the patient, including (but not limited to) nurses, physicians, social workers, physiotherapists, occupational therapists, speech therapists, pharmacists, dietitians, and healthcare aides. Five studies reported inclusion of non-professional clinical and support staff in their program delivery, including, for example, environmental services, maintenance, housekeepers, clerical staff, students, porters and laboratory and diagnostic technicians [44‐46, 53, 74].

Table 2 states how many learners were included in the education intervention. Eleven studies did not state how many learners were educated or it was unclear [48, 58, 61, 62, 66, 67, 69, 71, 74, 75, 78]. One study only reported the percentage of staff trained [49]. Another reported educating ‘change agents’ from 256 nursing homes but not the final number educated [71]. For some studies, there appeared to be a gradual attrition rate from the start of the study, to the completion of the educational content and subsequent completion of post study surveys.

Additional file 5 describes the Process elements of educational interventions. Twenty-one studies reported that teachers were trained in how to deliver the program. Twenty-six studies reported that there were pre-determined learning objectives. Of these, fourteen studies reported their objectives in behavioural terms. Eleven studies explicitly reported recognising learners’ prior knowledge and a further eight studies appeared to informally recognise prior knowledge. Twenty-five studies reported some recognition of learners’ prior experience. Three studies did not state the learning and teaching methods employed and three studies had no apparent alignment between the learning and teaching methods and their learning objectives.

A range of teaching and learning activities were conducted across the studies and these are detailed in Additional file 6. The approaches employed for educating staff about falls prevention mainly focused on three larger categories: methods of delivery, interactive learning activities/ experiential learning, and supported learning. There were three other minor categories: written learning material, assessments and ‘other’ which included teleconferences. These categories are detailed in Table 3. Often studies engaged a number of approaches.

Additional file 7 describes the Product elements of educational design. Thirty-two studies evaluated clinical outcomes, and twenty-seven studies evaluated educational outcomes. Thirty studies assessed learners’ achievements of the learning objectives of stated purpose of the education program and twenty-nine studies conducted an evaluation of the education program. Data reported to evaluate the educational interventions included: pre and post knowledge tests; use of validated scales such as the Environment Assessment Scale, Mayo High Performance Teamwork Scale, Perceived Quality of Care Scale, and Safety Organizing Scale; ongoing process evaluation; observation of falls prevention interventions implemented post-education; questionnaires targeting knowledge change and practice change; and analysis of focus groups. Where clinical data was used to evaluate the education interventions, this was usually fall rates per 1000 bed days.

Using a checklist based on the expanded 4Ps model, a summary table of a number of quality metrics was created, including whether the resources required were outlined, teacher and learner characteristics and evaluation planning (Table 4).

None of the studies we evaluated used a quality framework to design their intervention, and few studies reported the different elements required for developing and reporting an education intervention. Inadequately describing the key elements of a research study means that others are unable to apply and replicate the methods [87]. For example, a core principle of education interventions is the educational dose intensity [88]. However, in the studies that we reviewed, the duration of the education interventions, the learning environment and other relevant information to characterise the dose was often difficult to find.

Use of the 4Ps framework [37], may assist a quality assurance process where all key elements are considered in the design and reporting of health professional education programs. This has been used successfully in other health professional contexts such as in interprofessional learning [89‐91] and simulation-based education (SBE) [84]. In the SBE context, Cheng and colleagues argue for an improvement in the quality of reporting for SBE and have developed and published guidelines for healthcare simulation research inclusive of educational design features [84]. The use of standardised reporting of education design according to these types of frameworks will focus attention to the important elements for quality improvement into the future.

We found discrepancies in the content of education programs in studies with multiple teaching and learning strategies employed, which made the efficacy of each component difficult to determine [86]. Additionally, education interventions were poorly described, limiting the ability of the reader to fully understand the process, as well as making replication challenging. Formal delivery was the most common teaching strategy. Studies optimising health professions education in other diseases such as heart failure [92] and cancer [88] have demonstrated the importance of active learning for adult learners to improve their self-efficacy and level of knowledge of the disease. A scoping review that examined concussion education programs found that the education programs had limited use of interactive tools, delivered education at one time point only and lacked long-term assessment [93]. Our review revealed that whilst didactic lectures was the most common form of delivery, this was usually combined with other interactive learning activities, including skills training, or supported learning, with feedback or coaching. The time spent on education also varied greatly making it difficult to determine the most efficient and cost effective manner [86]. Many delivered education at one time point only, whilst others recognised the importance of follow up and reinforcement sessions via team meetings, teleconferences, peer to peer feedback or bedside coaching. More research is needed to determine the education program processes that could improve participants’ long term knowledge, attitudes and behaviours after being exposed to a falls education program [93].

Primarily, the outcomes were often measured in clinical terms, related to the number of falls, rather than behaviour change. The methods employed for outcome measurement also varied with quantitative instruments such as surveys, quizzes and questionnaires being the most common evaluation tools. The wide variety of approaches make it difficult to compare studies. Using robust and validated outcome measures will improve this field. Recommendations made on reporting outcome measures for cancer pain educational interventions, stated that all study designs should report on the prospectively selected primary outcome, and the tools and tests used to achieve this [88].

Evaluation of clinician training is often considered to be a low priority [94]. Application of the extended 4Ps model [37] to the studies in this review of education interventions in falls prevention, has provided stratified assessment of the use of education evaluation which highlights stronger study designs without unnecessarily discounting partially helpful information [95]. Evaluating the behavioural outcomes of education programs is important given that behaviour change is an important goal of the education. It is therefore recommended that the primary endpoints for research on health professional education programs in falls prevention should not only focus on falls and injury rates and costs. The clinical assumption of patient benefit as a reference standard of evidence should be rejected [95] and we call for researchers to also measure behavioural outcomes. Effective training measured in terms of behavioural change, such as the transfer of knowledge and skills gained from training into practice [88, 96], may potentially lead to a reduction in the rate of falls. The evaluation of education interventions using qualitative and quantitative measures could be incorporated into future falls prevention education programs for health professionals [95].

Including the synthesis of qualitative and quantitative research in the same review [97], and balancing the breadth and depth of analysis [98], was challenging. The sources of evidence for this review are limited because we excluded articles that were not published in countries with similar pedagogical approaches, only reported on falls prevention to health professionals in hospitals or healthcare facilities, and excluded non-empirical studies. Reporting of training undertaken for the teachers or facilitators of the education interventions could be considered as an addition to the framework in future studies. The application of the extended 4Ps model as a quality assessment tool for evaluation of educational reporting was theoretically driven. The 4Ps model awaits further formal validation [37].