Table Of ContentDEVELOPING AN EDUCATIONAL PROGRAM FOR STAFF IN ASSISTED LIVING
AND PERSONAL CARE HOMES ON RECOGNIZING FALL RISK AND FALLS
PREVENTION
by
Mary T. Marchetti
B.S., Physical Education/Adapted Physical Education, Bridgewater State College, Brgidewater,
MA, 1989
B.S., Physical Therapy, University of Pittsburgh, Pittsburgh, PA, 199 2
M.S., Physical Therapy with Neuromuscular Focus, University of Pittsburgh, Pittsburgh, PA,
1998
Submitted to the Graduate Faculty o f
School of Rehabilitation Sciences in partial fulfillment
of the requirements for the degree o f
Doctor of Philosophy
University of Pittsburgh
2014
UNIVERSITY OF PITTSBURGH
SCHOOL OF REHABILITATION SCIENCES
This dissertation was presented
by
Mary T. Marchetti
It was defended on
April 10, 2014
and approved by
Mark S. Redfern, PhD, Vice Provost of Research, Professor of Bioengineering; Professor,
Departments of Otolaryngology, Physical Therapy and Rehabilitatio n
Nicholas G. Castle, PhD, Professor, Health Policy and Managemen t
Jennifer Brach, PhD, PT, Associate Professor, Department of Physical Therap y
Stephanie Studenski, MD, National Institutes of Healt h
Dissertation Advisor: Susan L. Whitney, PhD, PT, Professor, Dpeartments of Physical
Therapy, Otolaryngology and Clinical Translational Science Institut e
ii
Copyright © by Mary T. Marchetti
2014
iii
DEVELOPING AN EDUCATIONAL PROGRAM FOR STAFF IN ASSISTED
LIVING AND PERSONAL CARE HOMES ON FALL RISK AND FALL
PREVENTION
Mary T. Marchetti, PhD
University of Pittsburgh, 2014
Assisted living facilities (ALFs) and personal care homes (PCHs) are becoming more common
along the spectrum of living arrangements for older adults. These bridge the gap for those who
University of Pittsburgh, [year]
can no longer live independently, but who do not require nursing home care. Federal regulations
are established for nursing homes, however very few federal regulations govern ALFs/PCHs.
These are primarily regulated by each state, and currently, there are few regulations regarding the
training of the staff who primarily provide care to the residents. Falls are a common cause of
both morbidity and mortality in older adults. The purpose of this study was to develop an
educational program to be provided to non-professional staff in ALFs/PCHs to enhance their
ability to recognize increased fall risk in residents, as well as develop an awareness of fall
prevention techniques. Because there is very little in the literature regarding training staff in this
setting, multiple steps were taken in the development of this program. The topics to be covered
in the program were determined by a thorough review of the literature related to falls in older
adults, the ALF/PCH setting, educational theory, and training of similar staff in the nursing home
setting. Observations were completed on all three shifts (day, evening and night-time) at two
local PCHs to identify problems that may be specific to this setting. To further refine content, a
survey utilizing the Delphi Method was done, with geriatricians, occupational therapists,
physical therapists and registered nurses, all of whom had experience in this setting and expertise
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in older adults. A pre-test and post-test was developed, utilizing cognitive interviewing to refine
the test questions. The educational program was then presented at six local ALFs/PCHs. Based
on pre-test/post-test scores, a statistically significant gain in knowledge occurred through the
program. This statistically significant change from baseline understanding of fall risk/fall
prevention was sustained over periods ranging from six weeks to three months, based on repeat
testing. Based on feedback provided by participants, they generally found this program to be
helpful useful in their day to day interactions with the residents.
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TABLE OF CONTENTS
1.0 INTRODUCTION ........................................................................................................ 1
2.0 BACKGROUND .......................................................................................................... 4
2.1 ROLE OF ASSISTED LIVING FACILITIES IN THE CONTINUUM OF
CARE FOR OLDER ADULTS ........................................................................................... 4
2.2 TRAINING OF STAFF IN ASSISTED LIVING FACILITIES ..................... 6
2.3 FALLS IN OLDER ADULTS............................................................................. 8
2.3.1 Injuries Sustained Due to Falls....................................................................... 9
2.3.2 Risk Factors Related to Falls in Older Adults ............................................ 12
2.3.2.1 Role of visual system in postural control .......................................... 13
2.3.2.2 Role of vestibular system in postural control ................................... 14
2.3.2.3 Role of somatosensory system in postural control ........................... 15
2.3.2.4 Summary of sensory contributions to postural control ................... 16
2.3.2.5 Other factors contributing to postural control................................. 17
2.3.2.6 Age-related changes affecting balance .............................................. 19
2.3.2.7 Extrinsic Risk Factors for Falls ......................................................... 24
2.3.2.8 Falls in Long Term Care .................................................................... 33
2.3.2.9 Cost of Falls in Older Adults .............................................................. 33
2.3.2.10 Summary ............................................................................................ 35
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2.4 EDUCATION FOR STAFF IN ASSISTED LIVING .................................... 36
2.4.1 Educational Theories ..................................................................................... 36
2.4.2 Reading level .................................................................................................. 40
2.4.3 Cognitive interviewing .................................................................................. 44
2.4.4 Training of Certified Nursing Assistants..................................................... 46
2.4.5 Summary of educational issues .................................................................... 47
2.5 OVERVIEW SUMMARY ................................................................................ 49
3.0 DEVELOPMENT OF EDUCATIONAL PROGRAM ........................................... 51
3.1 OBSERVATIONS AT ASSISTED LIVING FACILITIES/PERSONAL
CARE HOMES ................................................................................................................... 51
3.1.1 Methods .......................................................................................................... 51
3.1.2 Analysis of Observations ............................................................................... 52
3.1.3 Results ............................................................................................................. 53
3.1.4 Discussion/Limitations .................................................................................. 54
3.2 THE DELPHI METHOD OF SURVEYS ....................................................... 59
3.2.1 Methods: The Participants .......................................................................... 60
3.2.2 Methods: Survey Development .................................................................... 63
3.2.3 Results ............................................................................................................. 64
3.2.4 Discussion/Limitations .................................................................................. 65
3.3 DEVELOPMENT OF PRE- AND POST-TESTS .......................................... 69
3.3.1 Methods .......................................................................................................... 69
3.3.2 Results ............................................................................................................. 70
3.3.3 Discussion ....................................................................................................... 74
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3.4 PRIMARY STUDY ........................................................................................... 78
3.4.1 Subjects ........................................................................................................... 78
3.4.2 Methods .......................................................................................................... 80
3.4.3 Data analysis .................................................................................................. 84
3.4.4 Results ............................................................................................................. 86
3.4.4.1 Results from all participants across all facilities: day of
presentation ........................................................................................................ 89
3.4.4.2 Results from target audience across all facilities: day of
presentation ........................................................................................................ 91
3.4.4.3 Results from other participant groups across all facilities: day of
presentation ........................................................................................................ 92
3.4.4.4 Results of all participants across all facilities: follow up testing ... 95
3.4.4.5 Results of target audience across all facilities: follow up testing ... 97
3.4.4.6 Results of all other participant groups across all facilities: follow
up testing............................................................................................................. 99
3.4.5 Discussion/Limitations ................................................................................ 108
APPENDIX A: PERSONAL CARE HOME OBSERVATIONS ........................................ 131
APPENDIX B: DELPHI METHOD SURVEY ..................................................................... 183
APPENDIX C: COGNITIVE INTERVIEWS ...................................................................... 194
APPENDIX D: EDUCATIONAL PROGRAM .................................................................... 220
BIBLIOGRAPHY ..................................................................................................................... 453
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LIST OF TABLES
Table 1. Age-related system changes ............................................................................................ 20
Table 2. Risk factors related to falls in older adults ..................................................................... 24
Table 3. Environmental factors related to falls in older adults .................................................... 25
Table 4. NAAL scoring................................................................................................................ 42
Table 5. Literacy performance level according to level of education .......................................... 42
Table 6. Results of all participants across facilities taking both pre-test and the post-test .......... 90
Table 7. Likert scale evaluation immediately post-educational program, all participants ........... 90
Table 8. Results of all RCAs across facilities taking both the pre-test and the immediate post-test
....................................................................................................................................................... 91
Table 9. Results of all RCAs across facilities taking both the pre-test and the immediate post-test,
facility 6 removed ......................................................................................................................... 91
Table 10. Results of all LPNs/RNs combined across all facilities ............................................... 92
Table 11. Results of all participants identified as only "nursing," combined across all facilities;
includes RCAs, LPNs and RNs .................................................................................................... 93
Table 12. Results of pre-test and immediate post-tests of all participants identified as
housekeeping across all facilities .................................................................................................. 93
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Table 13. Results of pre-test and immediate post-test for all non-caregiving staff combined
across all facilities ......................................................................................................................... 94
Table 14. Results on pre-test and immediate post-test by participants without any identifying
marks on their tests, combined across all facilities ....................................................................... 95
Table 15. Comparison of pre-test, immediate post-test, and follow up post-test scores from all
participants combined among all facilities ................................................................................... 96
Table 16. Comparison of pre-test and immediate post-test scores among all participants across all
facilities who completed all three tests ......................................................................................... 96
Table 17. Comparison of pre-test and follow up post-test scores among all participants across all
facilities ......................................................................................................................................... 96
Table 18. Comparison of immediate post-test and follow up post-test scores among all
participants across all facilities who completed all three tests ..................................................... 97
Table 19. Program evaluation at follow up, all participants across all facilities .......................... 97
Table 20. Comparison of pre-test, immediate post-test and follow up post-test scores of all RCAs
across all facilities who took all three tests ................................................................................... 98
Table 21. Comparison of pre-test and immediate post-test scores of all RCAs across facilities . 98
Table 22. Comparison of pre-test and follow up post-test scores of all RCAs across all facilities
....................................................................................................................................................... 99
Table 23. Comparison of immediate post-test and follow up post-test scores of all RCAs across
all facilities .................................................................................................................................... 99
Table 24. Comparison of pre-test, immediate post-test and follow up post-test of all LPNs/RNs
across all facilities ....................................................................................................................... 100
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