Journal of Gerontological Nursing

Frequent Fallers: Leading Groups to Identify Psychological Factors

Barbara Ayn Wright, RN, CFNP, CGNP; Shirley Aizenstein, RN, MSN; Gale Vogler, RN, BSN; Myrna Rowe, RN, BSN; Carol Miller, RN, MA

Abstract

Prevention of falling is of great concern in geriatric nursing homes. Efforts to prevent falls in all settings have included targeting elimination needs; restraint application, and identification of high risk based on assessment at admission.'"3 Nursing homes are presented with a puzzling dilemma, however, because often the diagnosis, age, and general condition of frequently falling residents is indistinguishable from that of non-falling residents. Thus, there are questions about possible psychological factors contributing to the high risk of falling. If such factors can be identified, psychosociaí interventions might be developed to enhance prevention of falls.

PROCESS

In our Midwestern long-term care nursing home, the geriatric nurse practitioner (GNP) conducts 6-month audits of incident reports, a program begun in 1983. In 1988, 37% of the residents fell. However, 50% of those residents fell more than once in the study time. This 50% of the falling population generated 80% of the recorded falls. These repeated frequent fall percentages mirror previous audits of falls in this facility and as found by others.4'6

While preparing the audits, the GNP found that frequently falling residents often had the same diagnosis as other residents who did not frequently fall. For example, Mr. L, age 74 years, who has advanced Parkinson 's disease, falls frequently whereas Mr. W, aged 79, who also has advanced Parkinson's disease, does not fall. Both are ambulatory, continent, independent in eating, and are assisted in activities of daily living.

The GNP was curious about a possible psychological factor in frequently falling residents. In a planning session, the nursing administration team discussed the feasibility of bringing together a group of frequent fallers for education, support, snaring, and to learn more about preventing falls. Possible barriers were identified. It was unknown if the falling elderly would show interest in such a group; many residents were not "joiners" and did not attend or participate in groups. Additional questions were raised regarding who could best lead such a group, what material should be covered and at what level, and whether several sessions might be more successful than a single one.

The nursing administration team discussed the feasibility of certified nurse aides (CNAs) leading groups for frequently falling residents. Possible factors for the success of this project included: CNAs were experienced with falls and falling residents, CNAs were well known to the residents, and CNAs were "hands-on" caregivers. Thus, it appeared that CNAs were likely to be successful in group work with frequent fallers.

METHOD

This article describes a pilot project of groups held for frequently and single falling residents in a long-term nursing home. The groups were led by nurse aides. Two nurse observers identified psychological factors from their observation of the group process, the feelings and values expressed by participants, and the affect displayed.

* fear of transfer within the nursing home to a more dependent unit.

* Fear that a family member would sue the institution, something this particular faller did not want to have happen.

When these fears were expressed individually, the group agreed. The observers noted that the group was intense and energetic in expressing the importance of self-reliance. The frequent falls experienced did not mean increased frailty to these persons. The defense mechanism of displaced blame allowed the frequent fallers to continue to view themselves as intact, and they recognized and supported each other in this position. The nurse observers interpreted this complex behavior expression as a fiercely defended sense of independence.

FOLLOW-UP INTERVENTION

After the psychological factors were identified in the group sessions for frequent fallers, it was decided to have two additional group sessions for residents who fell only once.…

Prevention of falling is of great concern in geriatric nursing homes. Efforts to prevent falls in all settings have included targeting elimination needs; restraint application, and identification of high risk based on assessment at admission.'"3 Nursing homes are presented with a puzzling dilemma, however, because often the diagnosis, age, and general condition of frequently falling residents is indistinguishable from that of non-falling residents. Thus, there are questions about possible psychological factors contributing to the high risk of falling. If such factors can be identified, psychosociaí interventions might be developed to enhance prevention of falls.

PROCESS

In our Midwestern long-term care nursing home, the geriatric nurse practitioner (GNP) conducts 6-month audits of incident reports, a program begun in 1983. In 1988, 37% of the residents fell. However, 50% of those residents fell more than once in the study time. This 50% of the falling population generated 80% of the recorded falls. These repeated frequent fall percentages mirror previous audits of falls in this facility and as found by others.4'6

While preparing the audits, the GNP found that frequently falling residents often had the same diagnosis as other residents who did not frequently fall. For example, Mr. L, age 74 years, who has advanced Parkinson 's disease, falls frequently whereas Mr. W, aged 79, who also has advanced Parkinson's disease, does not fall. Both are ambulatory, continent, independent in eating, and are assisted in activities of daily living.

The GNP was curious about a possible psychological factor in frequently falling residents. In a planning session, the nursing administration team discussed the feasibility of bringing together a group of frequent fallers for education, support, snaring, and to learn more about preventing falls. Possible barriers were identified. It was unknown if the falling elderly would show interest in such a group; many residents were not "joiners" and did not attend or participate in groups. Additional questions were raised regarding who could best lead such a group, what material should be covered and at what level, and whether several sessions might be more successful than a single one.

The nursing administration team discussed the feasibility of certified nurse aides (CNAs) leading groups for frequently falling residents. Possible factors for the success of this project included: CNAs were experienced with falls and falling residents, CNAs were well known to the residents, and CNAs were "hands-on" caregivers. Thus, it appeared that CNAs were likely to be successful in group work with frequent fallers.

METHOD

This article describes a pilot project of groups held for frequently and single falling residents in a long-term nursing home. The groups were led by nurse aides. Two nurse observers identified psychological factors from their observation of the group process, the feelings and values expressed by participants, and the affect displayed.

Photos courtesy of the authors, Annen· berg Health Club in Lieberman Centre. Picture at the far left, from right to left: Cheryl Lemer, RN, Minnie Becker, Ted Lewin, Marcella Schreiber, IuKa Panzer, Rose Poster and Isabelle fackson. Second picture: Rose Poster. Third picture: Sadie Pilot (front) and Dora faffe. Picture at the far right, from right to left: Julia Pamer, Marcella Schreiber, Ted Lewin, Minnie Becker, Cheryl Lemer, RN, Harry Leavitt, Dora faffe, Marjorie Dulay.

Photos courtesy of the authors, Annen· berg Health Club in Lieberman Centre. Picture at the far left, from right to left: Cheryl Lemer, RN, Minnie Becker, Ted Lewin, Marcella Schreiber, IuKa Panzer, Rose Poster and Isabelle fackson. Second picture: Rose Poster. Third picture: Sadie Pilot (front) and Dora faffe. Picture at the far right, from right to left: Julia Pamer, Marcella Schreiber, Ted Lewin, Minnie Becker, Cheryl Lemer, RN, Harry Leavitt, Dora faffe, Marjorie Dulay.

Photos courtesy of the authors, Annen· berg Health Club in Lieberman Centre. Picture at the far left, from right to left: Cheryl Lemer, RN, Minnie Becker, Ted Lewin, Marcella Schreiber, IuKa Panzer, Rose Poster and Isabelle fackson. Second picture: Rose Poster. Third picture: Sadie Pilot (front) and Dora faffe. Picture at the far right, from right to left: Julia Pamer, Marcella Schreiber, Ted Lewin, Minnie Becker, Cheryl Lemer, RN, Harry Leavitt, Dora faffe, Marjorie Dulay.

Photos courtesy of the authors, Annen· berg Health Club in Lieberman Centre. Picture at the far left, from right to left: Cheryl Lemer, RN, Minnie Becker, Ted Lewin, Marcella Schreiber, IuKa Panzer, Rose Poster and Isabelle fackson. Second picture: Rose Poster. Third picture: Sadie Pilot (front) and Dora faffe. Picture at the far right, from right to left: Julia Pamer, Marcella Schreiber, Ted Lewin, Minnie Becker, Cheryl Lemer, RN, Harry Leavitt, Dora faffe, Marjorie Dulay.

Setting and Sample

The setting was a 240-bed skilled and intermediate nursing home in suburban Chicago. The population had a mean age of 85 years; the median and mode are 87 years. Frequent fallers were defined as those residents who had two or more falls in a 6-month period; single fallers were those residents who experienced one fall in the 6-month study. A fall is defined as an abrupt position change to horizontal, knees, or sitting position.

The nursing team assessed the frequent fallers to target those most likely to cognitively recognize the material. However, frequent fallers were not excluded on the basis of hearing or sight loss or psychological conditions.

Intervention

Groups were conducted by CNAs in 30-minute sessions. Educational materials for the groups were developed by the GNP responsible for auditing falls. For the first week, the group subject was "Falls and Feelings." The second week, the group centered on "How to Prevent Falls," and the third week, education about "Factors in Falling" was presented. Two groups were held once a week in different rooms for each of the three training sessions. They did not run consecutively; the first and second group meetings were separated by one week and the third group followed 6 weeks later. This occurred solely due to the logistics of scheduling the CNA time. Five to 10 frequently falling residents attended the groups per session.

Observations

Two nurse observers experienced in geriatrics documented the individual discussions and the group conversation. They each observed three sessions, making a total of six observed sessions. The nurse observers did not participate verbally in the CNA-led groups, but rather attended to give support to the aides, observe group process, and note the individual participation, affect, feelings, and values expressed by each of the frequent fallers.

Six groups met for 30-minute sessions. The attendance of frequent fallers was fairly consistent; however, one resident refused all sessions and others missed a session due to an acute illness, a visitor, or a clinic appointment.

RESULTS

The group members were enthused and attentive to the topics. Flach group held on these subjects was lively. Many common ties were revealed as the sessions progressed, in spite of the diversity of the group members.

First, many residents were baffled as to why they were included in the group as they did not see themselves as persons who repeatedly fell. Many felt they "slipped," "tripped," or "slid," but did not really "fall."

Secondly, residents harbored the thought that the aides resented being called to help them, so they tried to "do for themselves" without using the call light and, thus, they would fall. The aides responded with strong feelings of responsibility for resident falls and assurances (even apologies) about the residents' perceived sense of resentment by the aides.

The third factor identified by the nurse observers was a value of independence. Two observed behaviors led to this interpretation. Participants stated why they fell: "I fell because I got up"; "I fell because I'm too short and the closet is too high." The words to explain why the fall occurred made no rational sense. These remarks were followed by nods of agreement and verbal reinforcements by the others in the group. The candid, honest, persuasi ve, sincere manner of the participant's presentation followed by validation of the group was interpreted by the observers as the resident's investment in preservation of self-esteem. The group accepted the explanations that were given.

Fears were expressed by participants, but the fear of falling was not expressed, nor was the fear of fracture or injury. Rather, the fears expressed were of an entirely different nature:

* Fear of being belted in a wheelchair or restrained in any way as a consequence of the frequent falls.

* Fear that a family member would be informed of the falls (protocol specifies that a relative is called after each fall).

Photos courtesy of the authors, Annen· berg Health Club in Lieberman Centre. Picture at the far left, from right to left: Cheryl Lemer, RN, Minnie Becker, Ted Lewin, Marcella Schreiber, IuKa Panzer, Rose Poster and Isabelle fackson. Second picture: Rose Poster. Third picture: Sadie Pilot (front) and Dora faffe. Picture at the far right, from right to left: Julia Pamer, Marcella Schreiber, Ted Lewin, Minnie Becker, Cheryl Lemer, RN, Harry Leavitt, Dora faffe, Marjorie Dulay.

Photos courtesy of the authors, Annen· berg Health Club in Lieberman Centre. Picture at the far left, from right to left: Cheryl Lemer, RN, Minnie Becker, Ted Lewin, Marcella Schreiber, IuKa Panzer, Rose Poster and Isabelle fackson. Second picture: Rose Poster. Third picture: Sadie Pilot (front) and Dora faffe. Picture at the far right, from right to left: Julia Pamer, Marcella Schreiber, Ted Lewin, Minnie Becker, Cheryl Lemer, RN, Harry Leavitt, Dora faffe, Marjorie Dulay.

Photos courtesy of the authors, Annen· berg Health Club in Lieberman Centre. Picture at the far left, from right to left: Cheryl Lemer, RN, Minnie Becker, Ted Lewin, Marcella Schreiber, IuKa Panzer, Rose Poster and Isabelle fackson. Second picture: Rose Poster. Third picture: Sadie Pilot (front) and Dora faffe. Picture at the far right, from right to left: Julia Pamer, Marcella Schreiber, Ted Lewin, Minnie Becker, Cheryl Lemer, RN, Harry Leavitt, Dora faffe, Marjorie Dulay.

Photos courtesy of the authors, Annen· berg Health Club in Lieberman Centre. Picture at the far left, from right to left: Cheryl Lemer, RN, Minnie Becker, Ted Lewin, Marcella Schreiber, IuKa Panzer, Rose Poster and Isabelle fackson. Second picture: Rose Poster. Third picture: Sadie Pilot (front) and Dora faffe. Picture at the far right, from right to left: Julia Pamer, Marcella Schreiber, Ted Lewin, Minnie Becker, Cheryl Lemer, RN, Harry Leavitt, Dora faffe, Marjorie Dulay.

* fear of transfer within the nursing home to a more dependent unit.

* Fear that a family member would sue the institution, something this particular faller did not want to have happen.

When these fears were expressed individually, the group agreed. The observers noted that the group was intense and energetic in expressing the importance of self-reliance. The frequent falls experienced did not mean increased frailty to these persons. The defense mechanism of displaced blame allowed the frequent fallers to continue to view themselves as intact, and they recognized and supported each other in this position. The nurse observers interpreted this complex behavior expression as a fiercely defended sense of independence.

FOLLOW-UP INTERVENTION

After the psychological factors were identified in the group sessions for frequent fallers, it was decided to have two additional group sessions for residents who fell only once. Eight to 10 one-time fallers attended each session and were observed in a similar fashion as the frequent faller groups. The single fall groups were different from the frequent faller groups in that some residents with mild to moderate short-term memory loss were included. The subject for these two group sessions was "Falls and Feelings."

Observations With One-Time Fallers

Two distinct observations were made. First, some residents with memory loss did not remember the fall. These residents did not deny the fall, rather, they simply did not remember. One resident said, "If you say I fell, I must have."

Secondly, some single fallers had a clear memory of the fall, the events leading to the fall, and verbalization of a strategy to avoid the same fall again. One resident used the group as an opportunity to share her experience and to instruct the others on how to avoid the circumstances of a similar fall. She then demonstrated her technique to the others in the group.

CONCLUSIONS AND DISCUSSION

None of the falling residents verbalized a high degree of fear of falling as described in the literature.6·9 This may be because the group setting did not promote sharing this fear.

Frequent Fallers

The value of independence as a lifelong pattern correlates with the findings of Barbieri10 and Mitchell.8 Tideiksaar and Kay7 found in eliciting a history that patients stated they slipped or tripped, but did not fall. The frequent fallers in our groups also denied their falls and used similar words to describe what had happened to them.

Pablo11 found fallers who "were hesitant to call for assistance." Our findings support the existence of this attitude in our frequent fallers; however, we noted that the frequent fallers expressed not a reluctance to "bother the staff as Pablo stated,11 but rather a notion that the aides resented being called to assist the patient. Whether this was a true experience or based on the fallers' perception was not explored. This attitude may be a further expression of displaced blame.

The frequently falling residents' themes of high value for independence and denial are familiar. The emerging psychological profile appears to match that of the "major denier" as identified by Hackett and Cassem,12 In their study, 50 patients were studied for psychological reactions to being in a cardiac care unit; 20 of the 50 were found to be major deniers. These patients disclaimed fear and denied their conditions, stating they "experienced no anxiety as a result of their illness." They were fiercely independent.

One-Time Fallers

Residents who fell once did not deny the fall, and the strong theme of independence was not expressed. Residents with memory loss did not remember the fall; dementia clearly takes away from the resident any opportunity of learning from the experience of a fall. Other residents with clear memory of the fall appeared to be gaining control of the event by reflection and future planning. They saw their single fall as a preventable accident.

IMPLICATIONS

Although it is true that more older people fall, this is not inevitable with age nor is it a manifestation of normal aging. Institutions such as nursing homes house chronically ill, frail elders, and the very old, all of whom are at higher risk for falls. Yet, not all of these elders fall or fall frequently.

For those who are either frequent or single fallers, the CNA-led groups proved revealing in this pilot effort. Whether such clear themes would emerge in further group work with frequent and single fallers in geriatric long-term care facilities is provocative for future research.

Groves found that major deniers need to be identified by health-care workers because special techniques are needed to work with them. He speaks of the major denier as denying "without any self-destructive intent," and recommends working with the denial by appealing to the "patient's sense of sturdiness. "13 He cautions that "doomsaying authoritarian approaches typically fail" with the patient who is a major denier. He also notes that these patients frequently do not seek care from a physician.13

Identifying a faller who is a major denier is crucial and may be accomplished by having the elder share with the caregiver. Appropriate interventions are different for this person. Looking at this major denial as a strength to be supported could lead to a therapeutic approach appealing to these patients' sense of sturdiness and maintaining good health. Controlled research of ongoing group sessions for recognized frequent fallers who are major deniers in nursing homes is suggested to explore reducing the risk for repeated falls hi these persons.

Hackett and Cassem found that major deniers survive longer than nondeniers. l2 Prospective studies of recognized major denier frequent fallers for mortality are needed.

A medical evaluation of the symptom of falling must be pursued. If an appropriate work-up proves less than satisfying, identification of the major denier psychological triad of lifelong independence, denial of falls, and unwillingness to seek help may prove helpful to physicians and nurses who care for those elders. Individual or group work with such frequently falling elders merits future study and research to replicate and validate these findings.

fall-related fractures and other injuries from fall trauma represent a high risk to the health and well-being of elder persons. The financial cost is also high.14 Interventions targeting recognized major denier elders may enhance prevention of falls in nursing homes and other settings.

REFERENCES

  • 1. Garcia R, Cruz M, Reed PVT, Sloan G, Beran N. Relationship between falls and patient attempts to satisfy elimination needs. Nursing Management. I988;7:80V-80X.
  • 2. McHutchion E, Morse JM. Releasing restraints: A nursing dilemma. Journal of Gerontological Nursing. 1989; 2:16-21.
  • 3. Spellbring AM, Gannon ME, Kleckner T, Conway K. Improving safety for hospitalized elderly. Journal of Gerontological Nursing. 1988; 2:31-36.
  • 4. Berry G, Fisher RH, Long S. Detrimental incidents, including falls, in our elderly institution. J Am Geriatr Soc. 1981; 29(7):322-324.
  • 5. fberster J. A study of falls: The elderly nursing home resident. NYSNA Journal. I98I;12(2):9-17.
  • 6. Colling J, Park D. Home, safe home. Journal of Gerontological Nursing. 1983; 9(3):174-178, 192.
  • 7. Tideiksaar R, Kay A. What causes Mis? A logical diagnostic procedure. Geriatrics. 1986;41(12):32-39, 42-44, 47, 50.
  • 8. Mitchell R. Rills in the elderly. Nursing Times. 1984; January 11:51-53.
  • 9. Murphy J, Isaacs B. The post-fall syndrome. Gerontology. 1982; 28:265-270.
  • 10. Barbieri E. Patient falls are not patient accidents. Journal of Gerontological Nursing. I982;8(3):164-I73.
  • 11 . Pablo RY. Patient accidents in a long term care (acuity. Can J Public Health. 1977; 68:237-247.
  • 12. Hackett T, Cassem N. Psychological reactions to life-threatening illness. In: Abram H, ed. Psychological Aspects of Stress. Springfield, 111: CC Thomas; 1970.
  • 13. Groves J; Taking care of the hateful patient. NEnglJMed. 1977;298(16):883-887.
  • 14. The prevention of falls in later life: A report of the Kellogg International Work Group on the prevention of falls by the eiderly. Dan MedBull. 1987;34(Suppl4).

10.3928/0098-9134-19900401-07

Sign up to receive

Journal E-contents