Background
Significance
Methods and design
Sample and setting
Nursing home recruitment and randomization
Resident sample
Staff sample
Risks and challenges
The interventions
CONNECT Protocols | Rationale/Outcome | Who | Time |
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Learning Protocols
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CONNECT & Learn Protocols
CONNECT Basics (Session 1). Introduces local interaction strategies using storytelling and practice using role-play in context of falls prevention.
CONNECT Advanced (Session 2). Brief review followed by focus on the more advanced strategies of cognitive diversity, using storytelling, role-playing, and discussion of participants' experiences in applying concepts. | Interdisciplinary learning facilitates skill acquisition, creation of new horizontal and vertical connections among staff, and learning through cognitive diversity. | RNs, LPNs, NAs, social work, activities, rehab, MD, NP; dietary, administration | 2, 30 min sessions occurring 2 weeks apart (1.0 hrs total) |
In-House Facilitator Training Protocols
In-House Facilitator Class Training. In-house facilitators learn to facilitate interdisciplinary in-class learning and/or practice mentoring and problem-solving at the point of care to improve local interactions.
Chance Encounter Mentoring Training. Researcher shadows the In-house facilitator trainee during the work day to identify mentoring opportunities and model 'chance encounter mentoring;' observe and advise trainee as s(he) practices the behaviors; and jointly problem solve (1 session of 1 hr).
Support by research facilitators. The researcher contacts the in-house facilitators weekly for support and advising; in-house facilitators also have a phone number to call to seek help from research staff as needed. | Prepares in-house care and supervisory staff to build trust and maintain consistency of CONNECT with the local culture. Facilitates information exchange between nursing home staff and research staff. In-house facilitators develop self-efficacy in using chance encounters to model local interactions and to mentor staff. | Care staff or managers in clinical departments (e.g., nursing, social work, activities). Individuals self-selected with encouragement of study staff. | 1, 1 hr learning session; Up to 1 hr of shadowing during regular work activities; 5, 10 min discussions (up to 2 hrs, 50 min total) |
Relationship Map Protocols
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Group-to-group maps
Session 1. Researcher assists staff to describe actual interactions between work groups (e.g., NAs, LPNs, SW, Dietary, etc.).
Session 2. Researcher assists staff to depict new interaction patterns and develop guidelines for improved group-to-group interaction patterns. | Assists staff to make interaction patterns explicit (develop a group-to-group relationship map), and agree on guidelines for improved interactions. | Mid-level managers and selected LPNs, NAs. | 1, 1-hr class; 1, 70 min class; 1 week apart (2 hrs, 10 min total) |
Individual-to-individual maps
Researcher assists staff to draw an individual 'relationship map' that defines his/her ideal interactions with selected co-workers; reviews strategies for improving interactions. Participants learn to self-monitor and record interactions using relationship maps (available on a laminated card) and paper/pencil recording sheets. | Assists staff to evaluate relationships. Self-monitoring reinforces and sustains newly acquired behaviors and provides a measure of adherence and behavior change. | All CONNECT participants | 1, 30 min session (30 min total) |
Unit Based Mentoring Protocols
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Structured Mentoring (by Research Facilitator)
During the 2 weeks following each in-class session, the researcher engages each participant in a 10-min session to discuss and reflect on his/her experiences applying CONNECT concepts. The researcher uses a semi-structured guide to elicit concerns about using the strategies. | Facilitates authentic learning, which occurs only when learners can directly and independently apply concepts [75]. | All CONNECT participants | 2, 10 min sessions (20 min total) |
Chance Encounter Mentoring (by In-house Facilitator)
In-house facilitators engage in point-of-care discussions with staff to practice CONNECT behaviors and jointly problem solve, using the 'chance encounter' protocol. They record the number and descriptions of chance encounter mentoring sessions. At least 5 such encounters should occur daily during naturally occurring usual work activities. | Identifies staff concerns and barriers, facilitates ongoing learning about interaction, and strengthens sustainability of new behaviors. Facilitators learn to use existing time differently. | In-house Facilitators engage with floor staff in their department or work unit | 1.25 hrs/day for in-house facilitator (37 hrs total) |
FALLS Protocols | Rationale/Outcome | Who | Time |
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FALLS Coordinator and Team Role | |||
Training Session
Researcher reviews: 1) role of FALLS Coordinator and Team members; 2) Falls Management Program rationale and main components; 3) annotated slide presentation on practical aspects of fall prevention; 4) toolkit materials; 5) study expectations. | Falls Team members champion fall prevention, identify area to improve, monitor changes. | FALLS Coordinator, Falls Team, DON | 1, 4 hrs session |
Weekly FALLS Team teleconference
Researcher contacts FALLS team weekly during 3-month intervention for problem-solving/discussion, and highlights a topic from the Fall Management Program in more depth. Topics include 1) staff fall prevention education; 2) medications and falls 3) patient and family fall education; 4) orthostatic hypotension; 5) vision assessment and intervention; 6) gait and balance assessment and intervention 7) environmental assessment and intervention; 8)challenging behavior management; 9) establishing a culture of safety; 10) audit and feedback; and 11) Wrap-up and re-setting goals | Reinforces key concepts of multi-factorial risk reduction, supports FALLS Coordinator and maintains enthusiasm. | FALLS Coordinator, and any other team members s/he wishes | 11, 30 min sessions weekly (5.5 hrs total) |
Staff Education | |||
Case-Based Modules (online and paper form)
Nurse module. Covers impact, fall risk factor assessment and intervention focusing on orthostatics, gait, toileting, medications, environmental hazards.
NA module. Covers fall risk factor identification and intervention focusing on gait, footwear, toileting, hip protectors, and environmental hazards.
Prescriber/pharmacist module. Covers epidemiology/impact, risk factor assessment, risk factor reduction focusing on psychotropic medication reduction and Vitamin D. | Uses case-based learning to impart knowledge and change attitudes about multi-factorial fall risk reduction. | RNs, LPNs, NAs, MDs, NPs, PAs, Consultant Pharmacists and others (PT, SW, Activities etc) | 30-60 min |
Post-Fall Problem-solving | |||
Academic Detailing
Nursing home frontline staff is invited to participate in consultations with the researcher and FALLS Coordinator regarding their most challenging residents with falls, modeling risk factor assessment and multi-factorial interventions. Sessions occur at each nursing station during the day and evening shifts. | Reinforces key concepts and promotes behavior change and interdisciplinary discussions [75]. | Nurses, NAs, other interested staff | 2, 20 min sessions (40 min total) |
Audit and Feedback | |||
Feedback Report
Report uses visual (bar graph) and written depictions of the nursing home's current practice on fall-related process and outcome measures, and how this compares with peer nursing homes. Researcher presents and explains the feedback report to FALLS Team. | Identifies areas for improvement, promotes behavior change [75]. | FALLS team, others as desired by Falls Coordinator | 30 min |
Toolbox | |||
Morse Fall Scale: Validated scale that quantifies fall risk in nursing home residents; Nurse Fall Risk Reduction Worksheet: Prompts nurse to identify and modify reversible fall risk factors. Can be used for chart documentation; Prescriber/Pharmacist Medication Reduction Worksheet: Prompts consideration of dose reduction or discontinuation of high fall-risk medications, including lower risk substitution options; Environmental Checklist: Facilitates identification of hazards in resident room, bathroom, and common areas; Wheelchair maintenance log and stickers: Facilitates regular assessment and repair of wheelchair brakes; Fall Risk Fax Communication Form: Allows nurse/pharmacist to communicate concerns about medications with prescribers; Patient and Family Brochure: Describes interventions that the nursing home is using to reduce falls; Physician/Prescriber Brochure: Describes the fall reduction program and encourages review of medication reduction worksheets and faxes. | Provides modifiable tools to assist with communication, implementation, and documentation of multi-factorial risk reduction. | FALLS Coordinator determines dissemination | Voluntary |
Treatment fidelity
Design
Training
Delivery
Receipt of treatment
Enactment of skills
Recruitment and data collection procedures
Staff recruitment and consent
Staff incentives
Data collection from staff
Data collection from residents
Falls data sources and abstraction timing
Concept Measured; Source | Calculation/Definition | Includes six months prior to baseline | Includes six months after FALLS ends |
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Demographics; Medical record | Gender, Age, and Race. Nominal | X | X |
Fall rate; medical record, MDS, incident reports, census | Numerator: number of falls occurring in a 6-month period Denominator: number of occupied facility bed days | X | X |
Probability of recurrent falls; as above | Proportion of residents with two or more falls occurring in a 6 month period | X | X |
Fall risk reduction; medical record, MDS, incident reports | Count of documented fall risk reduction indicators defined below | X | X |
a) Orthostatic Blood Pressure | Documentation of blood pressure in two positions, OR discontinuing medication, adding volume expanding medication, compression stockings | X | X |
b) Sensory Impairment | Documentation of presence or absence of visual impairment, OR Intervention to change corrective devices, add assistive technology to optimize sensory input | X | X |
c) Footwear | Documentation that footwear was evaluated, modified, or recommended to patient | X | X |
d) Gait and Assistive Devices | Physical therapy assessment or training, change in assistive device, or participation in restorative ambulation program | X | X |
e) Toileting | Documentation of scheduled toileting or a previous attempt in residents with at least intermittent urinary or bowel continence | X | X |
f) Environment | Documentation of a search for environmental factors contributing to fall risk (e.g., low toilet seat, room clutter, burned out light bulb) OR a change in environment likely to reduce falls or injury risk, including repairing grab bars, changing floor surfaces, changing lighting, re-arranging furniture, using a low bed or floor mat, and alarms | X | X |
Dose reduction or discontinuation of any of the following classes of psychoactive medications within 1 month of a fall; benzodiazepines, tricyclic antidepressants, antipsychotics, propoxyphene, and selected anticholinergic agents (diphenhydramine, sedating antihistamines, immediate-release oxybutynin, skeletal muscle relaxants) | X | X | |
h) Calcium and Vitamin D | Prescription of at least 1,000 mg of calcium daily or 800 IU of vitamin D daily, OR equivalent dose regimens. Multivitamins containing vitamin D and combination calcium/vitamin D preparations will be added to the total daily dose calculation. | X | X |
Abstractor qualifications, training, and blinding
Data reliability
Measures
Concept Measured; Source | Psychometrics; Calculation |
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Demographics; self-report | Age, sex, job title, years in position, education, and ethnicity (collected at baseline or at enrollment into the study. Categorical measurement) |
Communication patterns; all staff | Mean scores on Roberts and O'Reilly openness, accuracy scales [79] and Shortell's timeliness scale [80, 81]. The scales show adequate reliability and validity in various settings [79, 80, 82]. In our preliminary studies scales showed reliability alphas of 0.81, 0.72 and 0.68, respectively; construct validity confirmed by factor analysis and hypothesis testing [17, 30, 83]. |
NA and LPN participation in decision making about resident care; all staff | Mean score on Anderson et al.'s [83] Participation in Decision-making Instrument (PDMI). The PDMI is established with demonstrated reliability in nursing homes [17, 18, 83‐85] and construct validity established through factor analysis [83] and hypothesis testing [17, 84, 86]. Nursing home samples achieved alpha coefficients of > 0.90. |
Relational Coordination; all staff | Mean scores on Gittell's [87] five-point scale on which staff will rate interactions between groups (e.g., NA to nurse, NA to dietary; nurse to MD). Three aspects are measured including: frequency of communication; high-quality communication; and supportive relationships [88, 89]. Gittell [88] adapted this scale for nursing homes and achieved a one factor scale and a Chronbach's alpha 0.86. In our preliminary study, we achieved an alpha of 0.95 on a sample of nursing home staff. |
Psychological Safety; All staff | Three items from Edmondson's 7-point psychological safety scale that were modified for heath care [90]. The items ask about whether people are comfortable checking with each other or asking questions, whether people value others' unique skills and talents, and whether people are able to bring up problems and tough issues [91]. Studies in healthcare settings reported alphas of 0.74 [91] and 0.73 [92] We slightly revised the scale by changing the word 'unit' to 'nursing home. Because the scale has not been used in a nursing home sample previously we tested the reading level and found that it read at the 6th grade level, which is acceptable for this low literacy sample. |
Safety organizing scale; all staff participants | Mean score on Vogus and Sutcliff's scale designed to measure five 'interrelated behavioral processes: preoccupation with failure, reluctance to simplify interpretations, sensitivity to operations, commitment to resilience, and deference to expertise' [93, p. 47]. In a large sample of hospital RNs, the 9-item, 7-point scale showed reliability (alpha = 0.88), convergent and discriminant validity, and criterion validity, and was reliability aggregated to reflect a unit-level construct [93]. We revised the wording for nursing homes. Alphas were > 0.90 in both the baseline and follow up survey in our preliminary studies. |