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Developing the React to Falls resources to support care home staff in managing falls

Abstract Objectives: Care home residents are falling three times more often than elderly frail people living in their own homes and as such, the management of falls is an important area for care home staff to consider. This paper outlines the development of the ‘React to Falls’ training resources to support care home staff in the management of falls. Methods: The ‘React to Falls’ resources were developed in collaboration with falls prevention researchers, expert clinicians working in the field of falls management in care homes and care home staff and residents. Results: A freely accessible online and paper based resource was developed to meet the needs of different care home settings. Expert clinicians and care homes emphasised the importance of promoting activity and quality life and ensuring the resources were a learning tool that supported positive risk taking. Expert clinicians highlighted the need to convey the importance of continually reacting to reducing risk in the management of falls. Conclusions: This study has developed a set of training resources on falls management to support care home staff to continually react and consider the risks and management of falls. An evaluation of the impact of the resource on care staff behaviour and organisational changes is recommended.


Introduction
The prevention of falls and injuries is a public health priority for all adults over 65 years of age 1 . 415,000 people live in care homes within the UK 2 and based upon conservative projections by the Joseph Rowntree Foundation, the number of care home places in the UK will increase by 150% by 2051 3 . The rate and risk of falls for care home residents is high with care home residents falling three times more often than elderly frail people living in their own homes 4 . Of those residents who fall nearly 1 in 10 suffer a fracture 5 , 1 in 5 is admitted to hospital 6 and 1 in 5 will die within the year as a result of a falls related injury 6 . Falls can have a significant impact on quality of life with a loss of confidence, loss of independence and reduction in activity. Many older people may become fearful of falling and subsequently do less activity because of their fear 7 . This lack of activity leads to poorer muscle strength and balance which increases their risk of further falls.
The randomised controlled trial evidence for falls management in care homes is of poor quality and the reduction in falls rates which have been seen in communitydwelling populations are not demonstrated by trial evidence in care home settings 8 . There are however well established risk factors that increase the risk of falling for older people which include falling in the last year, impaired mobility and impaired cognition 9 . A multifactorial assessment that identifies potential risk factors followed by tailored interventions to modify these risks is considered best practice 10 . In England there is national guidance through the NICE Guideline -Falls in Older People Assessing Risk and Prevention that recommends a multifactorial intervention with exercise component in extended care settings which includes care homes 9 . Despite this national guidance, this proactive approach of identifying and modifying falls risks to prevent falls and serious injuries is difficult to implement into a care home setting. Stakeholder discussions with care homes has identified that falls risk scores are commonly used which categorise residents as high, medium and low risk without appropriate individually tailored actions to modify risk. Care staff consider training to be a useful way of helping to develop their confidence and knowledge in the actions that they can help with to reduce the risk of falls 11 . Providing evidence of completing these actions in care home paper is challenging 11 , nevertheless 53% of identified actions are being completed, suggesting it can be achieved 12 .
Falls management in care homes requires consideration of the resident specific factors, such as levels of cognitive impairment and organisational and staff specific factors, such as knowledge of falls risk factors. The consideration of such factors are limited within clinical effectiveness trials and systematic review evidence which considers whether or not falls interventions work. Limited attention is given to which components work, under what circumstances. Working in collaboration with care homes to implement a falls management strategy, is more likely to be successful than strategies they have no ownership of, or may not be appropriate in their unique setting 13 .
One strategy to support implementation is providing training and resources for care home staff 14,15 . Ensuring that care home staff have sufficient and appropriate training is also supported by the NICE Quality Standard 86, 'Falls in older people: assessment after a fall and preventing further falls' 16 , that recommends that all health and social care practitioners involved in assessing, caring for and treating older people who experience a fall should have appropriate training to assess falls and their contexts. A large multi-centre study (the Falls in Care Homes trial with 87 care homes with 1698 residents across the UK 17 ) is currently evaluating a systematic falls prevention programme which includes training care home staff in identifying and carrying out actions to reduce falls risks. This large trial will provide insights into delivering faceto-face training with care home staff and whether this reduces falls rates, however it is acknowledged that alternative training methods may also be worth exploring.
In 2015 a training programme to raise the awareness of pressure area management was developed by clinical experts in tissue viability in one region within the UK. The resources included a 50 minute DVD, information booklet and a competency checklist following the training. Anecdotally the resources were welcomed by care home staff to support staff managing complex residents with complex needs. Care homes identified the need for resources to support in other areas of management, with falls considered an important topic, and the development of the 'React to Falls' resources was commissioned. This paper outlines the development of the 'React to Falls' training resources and how the resources were developed in collaboration with researchers, clinicians and care homes.

Methods
The 'React to Falls' resources were developed in collaboration with falls prevention researchers, clinicians working in the field of falls management in care homes and care home staff and residents. A study management group was established to govern the development process which consisted of a research physiotherapist, a NHS falls specialist physiotherapist, a NHS falls specialist occupational therapist, a Professor of Rehabilitation Research, an academic falls consultant, a research occupational therapist and a design consultant from Crocodile House Ltd. This group communicated through face-face meetings, teleconferences and e-mail correspondence.
Directed by the study management group, Figure 1 outlines the processes that were undertaken in the development of the resources with further detail presented below.

Review of existing care home resources
Existing resources for care home staff were critically reviewed by the research physiotherapist with regards to the content and format. These resources included local NHS organisation in house training programmes 18   Developing the React to Falls resources to support care home staff in managing falls

Discussion meetings with care staff
One-one discussions with care home managers, deputy mangers, carers and training leads were conducted at a care home in Nottingham City to gather their views on the scope, content and format of the resources.

Content development by expert clinician group
The clinical content of the resources were determined by an expert clinical group to ensure it was underpinned by the best available evidence and current clinical opinion. The expert clinical group consisted of two falls specialist nurses, one falls specialist physiotherapist and two falls specialist occupational therapists and was facilitated by the research physiotherapist.

Draft outline of planned resources
A draft outline of the planned content and format of the resources were developed by the study management group.

Resource Summary Appraisal
Falls in Care Home (FinCH) research study training manual One hour face-to-face standardised training based on the Guide to Action Tool delivered by NHS clinicians as part of a large randomised controlled trial.
Requires NHS clinicians to deliver training which limits sustainability in a real world setting.

RESHUFFLED
In house training package available for care homes in contact with NHS services delivered one NHS trust. 15 minute video using a single case study.
Not freely accessible to all care homes and requires log in with password. Series of videos available on YouTube with extensive management resources to assess and implement changes for improvement.
Comprehensive resource with multiple resources. Not specifically targeted at carers.

Care home and clinician feedback on planned resources
The draft outline of the planned resources was presented at a care home event in June 2018. This event was attended by 70 care home staff and clinicians from across the East Midlands. Written anonymous feedback was collated, which included; practicalities of online resources within a care home environment, alternative formats, key content for the resources and strategies to help care staff embed the information into daily practice.

Finalising and producing the resources
Key themes from the written care home feedback were identified by the study management group and used to review the draft outline of resources to ensure it met the needs of the care homes for whom it was intended.
Filming and photography was undertaken in one care home in the East Midlands in October 2018 with permission of the care home owner and manager. All residents, their families and care home staff were informed that the filming was to be undertaken and that participation was entirely voluntary. Written informed consent that detailed the purpose of the filming, data storage and how the footage would be used was obtained for all residents, family members and staff who took part in the filming and photography. For those residents who were assessed to not have capacity to provide consent for this decision, a consultee declaration from a family member was sought.
Resources were reviewed by an NHS falls consultant to ensure the quality and accuracy of the clinical content. The final resources were reviewed by the care home residents and staff who took part in the filming to confirm their acceptability.

Results
In collaboration with care homes, clinicians, researchers and research evidence the 'React to Falls' resources were produced. The aim of these resources were to encourage care home staff to continually react to manage falls, being mindful to promote activity and quality of life for the care home residents they support. An overview of the scope, format and content that was determined through care home and clinical collaboration is outlined below: • Scope: Awareness raising for care home staff to continually react and consider managing falls. For each of the stages of development outlined in Figure 1, a summary of the main findings and how this influenced the development is presented.

Review of existing resources
A summary of the resources is presented in Table 1. From this review it was identified the resources would be freely accessible without any input from NHS services, targeted specifically at care homes and specifically as awareness raising for care staff.

Discussion meetings with care home staff
Discussion meetings were held with care staff from a residential care home in Nottinghamshire in relation to the content and the format of the resources. A summary of the care staff views is presented in Figure 2. Care home staff considered falls to be an emotive and complex topic area and were not comfortable with completing a competency checklist to say they were component in the management of falls after using the resources. It was considered that awareness is a more appropriate term to use in relation to the management of falls due their complexity and difficulty preventing all falls. Care home staff considered it important to ensure the resources were developed to be representative of real word care home settings to ensure they were credible and legitimate. It was also considered important that the resources were a learning tool and avoidance of blame, if a fall did occur, needed to be avoided. Implicit within the resource was the promotion of enabling care home residents to move around as much as they wanted, within their capabilities. The importance of having easily accessible resources both online and in paper format was reinforced by care staff.

Content development by expert clinician group
Expert clinicians considered it was important that the resource reflected the balance of managing falls risk without compromising activity levels and reducing quality of life. The need to continually react to identify and manage falls risks was considered important to emphasise in each section of the resources. The expert clinician group determined the outline content which included; • Why are falls important to consider? • What is a fall? • What is the impact of a fall? • What are the risk factors for falling? • How to continually react to reduce the risk of falling? • The importance of recording and monitoring falls? • Case study examples to generate discussion about actions that care staff can take to manage falls.
The expert clinician group suggested using the acronym REACT TO FALLS with each letter representing a different risk factor (Figure 3) to support care staff in considering the whole resident when reviewing the risk factors.

Development of the draft outline
The draft outline of the resources included a website hosting all these resources for care homes to use as appropriate. The online resources would include website text, downloadable pdfs and short videos. An A4 printed booklet would accompany the online res ources. The outline of the planned sections and format is presented in Table 2.

Feedback on draft outline
Thirty-eight care home staff provided written feedback on the planned resources. Twenty four responded that online resources would be a useful format with 9 responding (5 did not provide a response) that online access would be limited within their care home environment, identifying paper based resources would be more appropriate. Alternative formats to support the online resources that were suggested included; pocket guides, learning conferences and workshops, being able to download resources from the website, badges for staff to promote the discussion of falls and posters to be displayed around the care home. Having a useful way of remembering the risk factors was welcomed however the REACT TO FALLS strategy was considered too long to remember and something 'short and snappy' was needed.
Other areas of development to consider included; providing the resources in different languages, providing information specifically for family, providing specific information on local referral pathways to clinical services and providing methods for evaluating the learning from the resources.

Final resources
The final resources incorporated the views of care staff and clinicians within the project constraints and included a freely accessible website -www.reactto.co.uk where all the React to resources are held. This provided a single point of access for all care homes to locate a series of resources addressing the needs of their residents. A series of short videos filmed in a real care home with care home residents and staff cover the key content. An A4 booklet and a pocket guide (example pages in Appendix A) provides the paper based resources which can also be downloaded from the website. REACT (Figure 4) was used as strategy for remembering the falls risk factors as it was considered shorter and conveyed the message of continually reacting.

Summary of findings
This study has developed a set of training resources on falls management to support care home staff to continually react and consider the risks and management of falls. A freely accessible online and paper based resource that can be used flexibly by each care home was developed to ensure it met the needs of the different care home settings. Expert clinicians and care homes emphasised the importance of promoting activity and quality life and ensuring the resources were a positive learning tool that supported positive risk taking. Expert clinicians highlighted the need for the resources to convey the importance of continually reacting to reduce the risk and manage falls and that it is not a discrete one off assessment but part of a continual process. Care staff considered the carer voice important to portray the guilt and blame which can be associated with falls in care homes.

Strengths and limitations
The strength of the development of these resources is that they have been developed through collaboration with care home staff, clinicians and researchers to ensure they offer a pragmatic resource to meet the needs of care homes that is underpinned by the best available evidence. Care home staff and residents participated in the production of the resources ensuring they represent a real world care setting and are credible to care home staff as the intended audience.
The work was, however, constrained by financial limitations with this work focusing on the development of the resources. It is acknowledged that further work is needed to develop strategies to support the learning from the resources, for example evaluating care staff knowledge before and after using the resources, learning forums and workshops and evaluating changes in care home practice. It was not possible to include all the content that was identified by care home staff. For example care staff considered the resources needed to outline which local clinical services could support them and how to access and refer to these services. As the resources were designed for all care homes in the UK covering the general principles of falls prevention, with varying provision of clinical services, it was not feasible to tailor the resources to individual need.

Wider context
The evidence to support the management of falls in care homes provides uncertainty over the optimal management for care home staff. The updated Cochrane review concludes uncertainty over the effects of multi-factorial interventions on falls rates with very little difference noted for falls risks 8 . Within this review it was also noted that there is a lack of evidence for training and education in reducing falls rates and risk in care settings. Despite the lack of robust evidence for falls management in long term care settings, residents, clinicians, care home staff and families are dealing with the very emotive subject of falls on a daily basis and further interventions are needed that target staff and organisational changes 8 . In long term care residents, a fall can often indicates underlying frailty and illness therefore a broad approach to assessment and management is indicated. Cameron and Kurle 21 suggest that the foundations of good clinical care for older people underpin effective falls management such as supporting mobility and activity, appropriate medicine management and identifying changes in health status. The 'React to Falls' resources align to this approach and emphasise the importance of considering the whole resident in continually reacting to manage falls. Developing the React to Falls resources to support care home staff in managing falls A key challenge in falls management is ensuring a positive approach that balances risk with supporting activity and participation which was emphasised by clinicians and care staff in the development of these resources. The decision to move into long term care may have been made by older people and their families due to the risk of living independently at home, perceiving a care setting as a safer environment 22 . Many residents themselves become fearful of falling and do less activity because of their fear, this then leads to poorer muscle strength and balance which in turn increases their risk of falls. Care staff and family may also take a protective approach due to their own concerns and anxieties of allowing activity given the potential risk of falls. In the development of these resources care home staff identified the need to educate family regarding this positive approach that continues to support quality of life, activity and participation. It is acknowledged that these resources are targeted at care home staff and further work is needed to develop the resources to provide support for family members. The Falls in Care Homes randomised controlled trial with embedded process evaluation, which is currently ongoing 17 , will also provide insights into the delivery of falls management in care homes and how to develop and support training programmes.
Reporting and monitoring falls, which was included in the 'React to Falls' resources, can be seen as a negative process designed to attribute blame. Identifying patterns and causes of falls can however ensure that action is taken to reduce future incidences and care home staff need to be supported to take a positive approach to recording and reviewing falls that enables accurate identification of modifiable risk factors. This pro-active approach to continually reacting to falls was conveyed in the 'React to Falls' resources. The challenge for the future is how we support a safety culture in care home that moves towards a positive approach to risk taking which respects the autonomy and choice of individual residents.
It is acknowledged that information giving alone may result in limited change in care staff behaviour and practice. Therefore, further consideration to how falls management is implemented in care homes is recommended. Care home staff value training and in a realist evaluation [unpublished] of the implementation of a falls prevention programme in care homes, it was found that care home staff valued training and support in the use of a new intervention. Absence of this training is a barrier to successful change. Further work is needed to develop strategies to support the implementation of the positive approach to falls managed outlined in the 'React to Falls' resources. An evaluation of the impact of the resource on care staff behaviour and organisational changes is recommended.

Conclusions and recommendations
The 'React to Falls' resources provide key messages in raising the awareness of falls management in care homes with the following key implications: • Promoting a positive approach to falls management. • Emphasising the care home staff and resident perspective. • Using the word REACT to continually react to manage falls.
The following are recommended as the next steps for further research and development: • Development of resources targeted at family members of care home residents. • Developing and evaluating implementation strategies to support care home staff behaviour change in the management of falls. • Evaluating the acceptability and use of the 'React to Falls' resources.