Assignment: Research Evidence Sources

Assignment: Research Evidence Sources
Assignment: Research Evidence Sources
84 February 2016 • Volume 20, Number 1 • Clinical Journal of Oncology Nursing Megan L. Kuhlenschmidt, BSN, RN, OCN®, Christina Reeber, BSN, RN, OCN®, Christine Wallace, MSN, RN, ACNS-BC, PCCN, Yanwen Chen, PhD, MS, Jill Barnholtz-Sloan, PhD, and Susan R. Mazanec, PhD, RN, AOCN® Background: Patients with cancer carry a higher risk for falls, potentially resulting in increased morbidity, mortality, and financial costs, as well as lower quality of life. Few evidence-based interventions are tailored to the patient’s perception of risk for falls. Objectives: This study aimed to determine the effect of tailored, nurse-delivered interventions as compared to a control group on patient perception of risk for falls, confidence in fall prevention, and willingness to ask for assistance. Methods: A two-group, prospective, randomized, controlled design was used to test the intervention in a convenience sample of 91 patients on an adult bone marrow transplantation unit. The intervention consisted of video and printed education tailored to the nurse’s risk assessment and the patient’s perception of risk. Patient’s self-reported perception, confidence, and willingness were measured at three time points: after consent within 24 hours of admission and at 24 and 72 hours after consent. The analysis consisted of a paired McNemar’s test stratified by intervention versus control group to examine differences between the groups. Findings: About one-third of patients perceived themselves to be at low risk for falls despite a nurse rating of high risk. A statistically significant difference existed in the proportion of patients who perceived themselves to be at high risk for falls pre- and postintervention (p = 0.01). Results suggest that tailoring education to the patients’ perceived risk for falls can help patients become more aware of fall risk. Megan L. Kuhlenschmidt, BSN, RN, OCN®, is a senior clinical nurse, Christina Reeber, BSN, RN, OCN®, is a care coordinator, and Christine Wallace, MSN, RN, ACNS-BC, PCCN, is a clinical nurse specialist, all in the Seidman Cancer Center at the University Hospitals Case Medical Center; and Yanwen Chen, PhD, MS, is a biostatistician in the School of Medicine, Jill Barnholtz-Sloan, PhD, is the associate director for bioinformatics and an associate professor in the School of Medicine, and Susan R. Mazanec, PhD, RN, AOCN®, is an assistant professor in the Frances Payne Bolton School of Nursing, all at Case Western Reserve University, all in Cleveland, OH. The authors take full responsibility for the content of the article. The authors did not receive honoraria for this work. The content of this article has been reviewed by independent peer reviewers to ensure that it is balanced, objective, and free from commercial bias. No financial relationships relevant to the content of this article have been disclosed by the authors, planners, independent peer reviewers, or editorial staff. Kuhlenschmidt can be reached at megan.kuhlenschmidt@uhhospitals .org, with copy to editor at CJONEditor@ons.org. (Submitted March 2015. Revision submitted May 2015. Accepted for publication May 7, 2015.) Key words: cancer; fall prevention; hospitalized falls; falls intervention Digital Object Identifier: 10.1188/16.CJON.84-89 n Article Tailoring Education to Perceived Fall Risk in Hospitalized Patients With Cancer: A Randomized, Controlled Trial © iStock.com/Angela Schmidt Falls in hospitalized patients are associated with poorer quality of life, greater disability, longer hospital stay, increased resource use, and greater risk of institutionalization (Hill et al., 2009). Falls are devastating to patients, family members, providers, and the healthcare system, with 34% of falls leading to injury (Fisher, Davis, McLean, & Le Couteur, 2005). Falls are defined as an unplanned descent to the floor that results from physiologic or environmental reasons and may occur with or without injury (Press Ganey Associates, Inc., 2015). The national average is 3.34 falls per 1,000 patient care days (Press Ganey Associates, Inc., 2015). During the past year, the falls rate on the inpatient bone marrow transplantation unit at the Seidman Cancer Center of University Hospitals Case Medical Center in Cleveland, Ohio, was an average of 3.2 per 1,000 patient care days. Of particular concern was that 8 of the 24 falls on the bone marrow transplantation unit in 2013 led to injury, which required additional treatment. ? Clinical Journal of Oncology Nursing • Volume 20, Number 1 • Tailoring Education to Fall Risk in Hospitalized Patients 85 Patients with cancer have several unique risks for falls and injuries in addition to general fall risk factors, which include neurologic and nutritional deficits related to cancer treatment, polypharmacy, and deconditioning from cancer-related fatigue (Capone, Albert, Bena, & Tang, 2012). Advanced age has also been associated with increased falls in oncology populations (O’Connell, Cockayne, Wellman, & Baker, 2005). Older adults often have an overly positive perception of their state of health in general and may underestimate their risk of falls (Hughes et al., 2008). Hospitalized adults with cancer are at an additional risk for falls because of factors unique to oncology populations (Wildes et al., 2014). Although not all falls are serious enough to require intervention, they may still lead to increased fear of another fall. This fear may restrict a patient’s activities of daily living (Verheyden et al., 2013). Primary sequelae of a fall include injury and postfall anxiety, with subsequent loss of independence through disability and fear of falling (Chang et al., 2004). Oncology treatments are often given during long hospital stays, and patients may feel a loss of control because of the extended length of treatments. Patients with cancer are at risk for rapidly changing health status and, therefore, need a different kind of falls surveillance than those in other inpatient care units (Filler, Kelly, & Lyon, 2011). Early intervention with patients with cancer at high risk for sustaining a fall is critical to prevent falls and injury. The substantial research of risk factors associated with falls in hospitalized patients has increased awareness that falls are multifactorial in nature and associated with multiple medical, functional, and cognitive factors (Tzeng, Hu, Yin, & Johnson, 2010). One area that has not been studied in depth is hospitalized patients’ perceptions of their risk of falling and sustaining an injury. A personal history of a previous fall was associated with greater awareness of fall risks in a survey study of 120 community-dwelling adults (Wiens, Koleba, Jones, & Feeny, 2006). Perceived risk is of particular concern in an oncology population because patients come to the inpatient setting in good health or may present with a new diagnosis, but they often believe that they are healthy and fit. They may not perceive that they are at an increased risk to have a fall. An integral component of primary prevention of falls is an evaluation of patient and caregiver awareness of the risk factors for falls (Sadowski, Jones, Gordon, & Feeny, 2007). Nurses have a unique body of knowledge and awareness of risk factors for patient falls and of falls that may cause injury. In addition, they have knowledge of the effectiveness of related interventions in inpatient care settings (Tzeng & Yin, 2012). However, nurses’ perceptions about the most frequent and preventable risk factors for injurious falls, as well as the most frequently adopted and most effective interventions, were found to be variable in a study of hospitalized patients (Tzeng & Yin, 2012). Patient education will likely be less effective if nurses’ perceptions of fall risk are inconsistent with those of patients. While patients are in the inpatient setting, nurses play a vital role in educating them about fall prevention. Accurate assessment about patient awareness of risk for falls is an important building block in any fall-prevention program or campaign (Wiens et al., 2006). Substantial evidence supports the effectiveness of multistrategy programs to reduce fall rates. However, the specific contributions of patient education and the impact of tailored messages are less researched (Hughes et al., 2008). A systematic review and meta-analysis of interventions for preventing falls and fall-related injuries among older adults found that multifactorial interventions, which require an individually tailored approach, can reduce falls (Goodwin et al., 2014). The ineffectiveness of an intervention to alter patients’ perceived risk for falls may reflect a failure to personalize the message in terms of individual risk (Hughes et al., 2008). Sadowski et al. (2007) suggested that one strategy for fall prevention may be for health professionals to assess a patient’s knowledge of the risk factors for falling routinely and then provide education in deficit areas. One trial tested an educational session in 1,822 older adults residing in nursing homes to target known risk factors, such as age, mobility status, and altered elimination (Ang, Mordiffi, & Wong, 2011). In high-risk individuals, this educational session significantly reduced the risk of falling. This finding suggests that education tailored to the patient’s specific risk factors might also reduce patient falls in the hospital setting. Patient education that is tailored to patient’s perceived risk is consistent with the Health Belief Model (HBM) developed by Rosenstock (1974). According to the HBM, perception of a threat, as well as perceived benefits, barriers, and self-efficacy, is directly related to behavior change. Therefore, a perception of higher risk of sustaining a fall would likely lead to greater engagement in preventive activities. However, most intervention studies are targeted to exercise, use of medications, and environmental adaptation (Verheyden et al., 2013). To the authors’ knowledge, no studies of interventions that are tailored to the patient’s perception of fall risk exist. The primary objective of this study was to determine the effect of a tailored, nurse-delivered intervention, as compared to a control group, on perceived risk for falls, confidence to prevent falls, and willingness to ask for assistance in hospitalized hematology/oncology patients. Secondary objectives were to describe the relationship between patients’ perceived risk for falling and (a) their willingness to ask for assistance with ambulation, (b) performance of nursing risk assessments, (c) incidence of sustaining a fall, and (d) patient satisfaction with the intervention. Methods Design, Setting, and Sample A two-group, prospective, randomized, controlled design was used to test the intervention in a convenience sample of 91 patients on an adult bone marrow transplantation unit. Inclusion criteria for patients were a cancer diagnosis; admission to the inpatient bone marrow transplantation unit; being alert and oriented to person, place, and time; and ability to speak English. Patients were excluded if they were actively dying or had a physician order for bed rest. Eligibility was not affected by any treatments or chemotherapy regimens that the patient was receiving. After approval from the institutional review board at University Hospitals Case Medical Center, patients were identified from the admission log kept by the division secretary. They were screened for eligibility via questions directed to the nurse caring for the patient. Patients were then approached, and written informed consent was obtained. ? 86 February 2016 • Volume 20, Number 1 • Clinical Journal of Oncology Nursing Based on clinical experience, the baseline proportion of individuals at high risk for falls at the cancer center was estimated to be 50%. Sample size was determined based on an initial hypothesis that 30% or more of the low-perception category would change to the high-perception category postintervention. Based on these proportions, at a 0.05 significance level with 80% power, 88 individuals, with 44 in the intervention group and 44 controls, were needed for the study. With an estimated 5% dropout rate, the final projected sample size was 91 patients. Measures The 15 education sheets and 4 videos were developed by the principal investigator. Content of the videos was determined by clinical practice guidelines and the literature. The content was validated by a team of clinical experts. The 15 education sheets addressed different topics, such as frequent toileting, sedating medications, and history of having a fall. Patient-specific risk factors for falls, ways to decrease the risk, and how the patient could work with the healthcare team to remain safe from a fall were included in the information sheets. Four videos were created with tailored messages for falls risk categories: (a) high perception of a fall by the patient or high risk for a fall as assessed by the nurse, (b) low perception of a fall by the patient or high risk for a fall as assessed by the nurse, (c) high perception of a fall by the patient or low risk for a fall as assessed by the nurse, and (d) low perception of a fall by the patient or low risk for a fall as assessed by the nurse. All videos were in English.