Abstract
We examined a brief measure of falls self-efficacy in nursing home residents participating in a pilot randomized controlled trial to study the effects of hip protectors on the prevention of fractures (N = 116, mean age 82 ± 8, 72% female). Internal consistency reliability was acceptable with Cronbach’s alpha of .79. Factor analysis supported two factors representing self-efficacy expectations and outcome expectancy. Contrasted groups comparisons and construct validity were examined. We found lower falls self-efficacy in participants who needed help with mobility, in people with lower executive function, and in participants who reported fear of falling. Scores were not associated with prospective falls or adherence with hip protector use. The findings of this study provide preliminary support for the reliability and validity of the scale for future research.
Researchers have demonstrated that fear of falling is an independent predictor of falls and functional decline; a negative impact on older adults in all settings including the nursing home (Chou, Yeung, & Wong, 2005; Warnke, Meyer, Bott, & Muhlhauser, 2004). In the first study of fear of falling in nursing home residents, Franzoni, Rozzoni, Boffelli, Frisoni, and Trabucchi (1994) found a prevalence of fear of falling in this population of 46%. More recent studies have found slightly higher rates of 50.5% (Blanchard, Myers, & Pearce, 2007) and 48.2% (Gillespie & Friedman, 2007). Fear of falling is associated with falls (Yeung, Chou, & Wong, 2006), function (Kato et al., 2008), depressive symptoms (Chou, Yeung, & Wong, 2005), and predictive of decline in activities of daily living (Franzoni et al., 1994) in nursing home residents. Concern about falls or injuries causes nursing home residents to avoid ambulation, reduce activity participation, and be less self-sufficient in personal care. Thus, fear of falling is a modifiable risk factor for functional decline in this population, deserving further inquiry.
Fear of falling can have different presentations in the older adult besides fear. Several related constructs are used in research (Jorstad, Hauer, Beker, & Lamb, 2005) and may be measured alone or with direct measures of fear of falling. The exact relationships between these constructs are not completely clear. Falls self-efficacy is the most commonly used construct and is defined as confidence in carrying out daily activities without falling (Tinetti, Richman, & Powell, 1990). Falls self-efficacy has been identified as a risk factor for falling (Moore & Ellis, 2008). Difficulty with balance is a predictor of developing fear of falling (Lach, 2005), and confidence in maintaining balance while completing activities is another related construct (Powell & Myers, 1995). Reduction in activities is a common outcome of fear of falling, so activity participation has also been examined (Lachman et al., 1998).
Excellent measures exist for measuring these different constructs. However, these current measures are complex and not appropriate for very frail older adults, and researchers have expressed concerns about their use (Kato et al., 2008). Some of the activities examined by these tools are not typically performed by nursing home residents, such as cooking, walking in crowds, shopping, or using public transportation. Additional measures are needed to assess fear of falling specific to this population. Therefore, we developed the Nursing Home Falls Self-Efficacy Scale (NHFSS) and tested it as part of a pilot study of hip protectors to prevent hip fractures.
Method
Participants
Participants for the pilot study were recruited from 14 nursing homes in a large metropolitan area to participate in a clinical trial of hip protectors. Participants were included if they were long-stay residents (nonrehabilitation), mobile without total assistance, had no history of bilateral hip fractures or bilateral hip replacements, were noncombative, were able to remain dressed for 6 or more hrs, had a hip circumference <49 in., did not have skin breakdown that would interfere with wearing hip pad underwear, and had a life expectancy >6 months. The NHFSS was administered to participants scoring <12 on the Short Blessed Test of Orientation, Memory, and Concentration (SBT; Katzman et al., 1983). Participants with more severe cognitive impairment were excluded because this was the first testing of the instrument, and we wanted to avoid this confounding issue.
Procedures
Following consent and enrollment of participants in the primary hip protector study, baseline data were collected. The NHFSS was administered by interview to qualifying participants, who were read the questions and shown a large print card with the response choices as a visual cue. After the baseline assessment, participants wore a hip protector on one side for up to 34 months so that they served as their own control (the protected hip vs. the unprotected hip). Trained research assistants visited participants, interviewed staff, and reviewed charts three times per week to monitor adherence to the intervention and prospective falls or hip fractures.
Measures
The baseline assessment included demographic information, interview questions, cognitive and physical assessments, and extraction of Minimum Data Set (MDS) 2.0 information (Centers for Medicare and Medicaid Services, 2008) from patient records. Self-reported fear of falling was assessed using a single item (somewhat, very, or not fearful), as was self-reported activity limitation (strongly agree to strongly disagree). The constructs of falls self-efficacy and outcome expectancy were measured with the NHFSS.
The NHFSS was developed through adapting items from other instruments to measure self-efficacy and outcome expectancy. The constructs are drawn from Bandura’s (1997) theory of self-efficacy which proposes that people’s beliefs about their capabilities impact how they behave in particular situations. There are two components that influence behavior: the ability to perform behavior (self-efficacy expectations) and beliefs about specific outcomes (outcome expectancy). Previous measures such as the Falls Efficacy Scale (FES; Tinetti et al., 1990) or Activities Balance Confidence Scale (Powell & Myers, 1995) have only measured the self-efficacy component. The NHFSS was designed to measure both theoretical constructs.
To measure self-efficacy expectations, the format of items from the Falls Efficacy Scale (Tinetti et al., 1990) was adapted to assess confidence in completing activities without falling. Activities commonly done by nursing home residents were selected with input from nurses who were currently collecting data in nursing homes for another study. They discussed different activities with their other research participants to help inform the items for this scale and met with the investigator to discuss final items. Three were selected: getting in and out of a chair, getting to and from the bathroom, and walking down the hall and back without falling. Participants were instructed to answer the questions regardless of how they did these tasks (i.e., with a walker, help of staff member, and the like). The 10-point scale used in the original FES was simplified to the 5-point scale used by Buchner et al. (1993), making answering less confusing for respondents while still allowing for variability. A higher score indicates greater falls self-efficacy or less concern about falling during the described activities.
To measure outcome expectancy, one item asked about residents’ confidence in their ability to continue completing their daily activities without falling, based on a similar outcome expectancy item used in studies of chronic disease (Lorig et al., 1996). A higher score indicates greater confidence. Two other questions were adopted from the Fear of Falling Questionnaire of Dayhoff, Baird, Bennett, and Backer (1994). This measure was designed to measure perceptions of potential harms from falling. Using a 4-point agree/disagree format of the original scale, participants were asked about their perceived risk of injury if they had a fall, and if they thought it would be difficult to recover from an injury if they fell. Stronger agreement indicates greater concerns about the outcomes of falling.
The cognitive assessment used the SBT which includes an item asking participants to repeat the months of the year backwards (TMYB), a measure of executive function (Ball, Bisher, & Birge, 1999). This component of the SBT has been identified as a predictor of falls and injurious falls in previous studies (Lord, Ward, Williams, & Anstey, 1994; Nevitt, Cummings, & Hudes, 1991). Participant scores were dichotomized to identify higher or lower executive function based on the presence or absence of errors on this item from the SBT.
The quarterly MDS assessment provided data on mobility levels of participants, use of assistive devices, history of injuries, and history of falls. Overall the MDS has shown acceptable validity (Morris, Jones, Fries, & Hirdes, 2004; Shin & Scherer, 2009). Mobility items were recorded and coded so that participants were considered to have high mobility if they were independent or only needed supervision walking in their room or in the corridor. Participants were considered low mobility if they needed physical help with walking.
Prospective falls and adherence to the hip-pad protocol were drawn from the parent study which included chart review and interviewing of residents and staff regarding falls three times weekly. Data on the falls over the 6 months following baseline data collection were used for this analysis.
Data Analysis
Data were analyzed using SPSS (Version 16.0; SPSS, Chicago, Illinois). Descriptive statistics were used to determine participant characteristics. Participants who responded as being either somewhat or very fearful of falling were combined to make one group of participants who had fear of falling for dichotomous comparison to those without fear of falling. Mean NHFSS scores were determined for each item and the total score along with the range and distribution of scores. Construct validity was assessed using exploratory factor analysis using maximum likelihood extraction, with varimax rotation. Internal consistency reliability was determined using Cronbach’s coefficient alpha. Convergent validity was tested using ANOVA to compare NHFSS scores based on self-reported fear of falling. ANOVA and t tests were also used to conduct contrasted group comparisons based on several variables associated with falls self-efficacy and fall risk identified from prior studies. These included history of falls, history of injury, use of an assistive device, executive function, and mobility. Predictive validity was examined by comparing the association between NHFSS scores and prospective falls and adherence to hip pad use over 6 months using t tests.
Results
Of the total hip protector study sample, 22.6% (118/521) passed the cognitive screen and completed the fear of falling assessment; two were excluded for incomplete data for a final sample of 116. Participants were primarily White (91%), female (73%), and ranged in age from 65 to 98 (82.6 ± 8.0). Overall, 62% of the sample reported that they were fearful of falling, and comparisons of participant characteristics by presence of fear of falling are presented in Table 1. Of all participants, 88% used some kind of assistive device, 19% had a prior fracture, and 46% were independent or only needed supervision ambulating in the room or hall. About one fifth (21%) had fallen in the past 180 days.
Characteristics of Participants (N = 116)
p = .019.
The mean score for participants for efficacy expectations items ranged from 3.03 ± 1.25 to 3.72 ± 1.24, and the outcome expectancy items ranged from 2.27 ± .72 to 3.72 ± 1.26 (see Table 2). Lowest scores were on the two agree/disagree outcome expectancy items. Each response category was selected on all six items, suggesting that the items were sensitive to variation in the population. Outcome expectancy items were recoded for analysis, such that higher scores for all items indicated more positive attitude toward fall outcomes, similar to the efficacy expectation items.
Mean NHFSS Scores by Fear of Falling
Higher score = greater confidence in continuing or completing activity without falling.
Recoded so that a higher score is positive = less concern about the outcome.
Correlations between items ranged from .12 to .76, with one correlation above .70. The factor analysis revealed that there were two factors. The proposed items representing the Efficacy Expectations subscale loaded on Factor 1 (see Table 3); however, a fourth item also loaded high on this factor (confidence in continuing current activities). Factor 1 had an eigenvalue of 2.29 after varimax rotation, explaining 39.8% of the variance. The other two items representing outcome expectancy loaded on Factor 2 which had an eigenvalue of 1.51 and explained 25.2% of the variance.
Factor Loadings of NHFSS Items
Note: KMO = .74; Bartlett’s = .0001.
The Cronbach’s alpha for the total scale was .79, suggesting acceptable internal consistency, with little improvement if items were deleted. The alphas of the final two factors were .84 for the Efficacy Expectations scale (four items) and .86 for the Outcome Expectancy factor (two items).
Evidence of convergent validity was assessed by comparing the scores for participants based on their perceived fear of falling, a concept closely related to falls self-efficacy. Based on this classification, those reporting fear of falling had significantly poorer scores on the total NHFFS and each of the items, compared with those without fear of falling.
Construct validity was evaluated by comparing NHFSS scores of contrasted groups, based on objective measures associated with increased fall risk. There were no differences in scores based on use of an assistive device or prior fracture. Those with good mobility, based on not needing physical help for walking, had significantly higher falls self-efficacy scores (3.14 + 0.74 vs. 2.93 + 0.78, p = .01) compared with those who needed help.
We then addressed whether NHFSS was associated with prospective falls and adherence to the use of the hip pads. There were 118 falls involving 45 participants (38%) in the 6 months after baseline testing. Of fallers, records indicated 53% were wearing a hip pad at the time of the fall. However, whether fallers were wearing the hip pads at the time of the fall was only recorded for two thirds of the fallers. NHFFS mean scores were slightly higher for those who had no falls (3.31 ± 0.72) over 6 months compared with those with two or more falls (3.12 ± 0.77), but neither were the differences significant nor were scores based on adherence to the hip pads at the time of a fall.
Discussion
This study provides preliminary support for the NHFSS for measuring falls self-efficacy in nursing home residents that can be used to explore this important problem. The NHFSS had acceptable internal consistency; factor analysis suggested some revisions are needed in the scale. Support for convergent validity was provided by examining the NHFFS scores for groups formed on the basis of fear of falling. Construct validity was supported by differences in NHFFS scores for contrasted groups based on mobility and executive function, and there was a trend based on history of falls.
This study is consistent with prior work; a high percentage of nursing home residents have fear of falling (62%; Franzoni et al., 1994). We found a higher level of fear of falling than others who reported levels below 50% (Blanchard et al., 2007; Franzoni et al., 1994; Gillespie & Friedman, 2007). Unlike community-based studies that have found fear of falling to be a risk factor for future falls (i.e., Hadjistavropoulos et al., 2007), participants reporting fear of falling at baseline did not have significantly higher rate of falls during the following 6 months. Participants may have been modifying their behavior to reduce fall risk or getting more assistance from staff. It is also possible that a longer period of follow-up may have shown differences.
Those with lower self-efficacy scores on the NHFSS (poorer efficacy expectations and outcome expectancy) were more likely to have lower mobility. Some of those participants may be overrestricting their activity, or staff may be discouraging residents from being independent, or overassisting them because of concerns about falling. The NHFFS did not discriminate between prospective fallers and nonfallers. This suggests a discrepancy between how participants evaluated their risk of falling and how they behave. This is consistent with prior work in community older adults who may not appropriately perceive their fall risk and take appropriate steps based on their actual risk (Delbaere et al., 2010). Some will overrestrict their activity and others may not be cautious enough. Given that decreased mobility and activity are clearly risks for future falls, nursing home residents with mobility problems, falls, or fear of falling need individualized interventions of exercise and potentially therapy to be sure they participate in regular physical and social activity to maintain strength and balance.
Lower self-efficacy scores were not associated with improved hip-pad adherence. Warnke et al. (2004) found fear of falling to be a weak predictor of hip protector use in their nursing home study. Our participants wore hip pads on only one side, therefore, may not have felt they were fully protected. In addition, wearing the hip protectors could be influenced by staff awareness of the study or many other factors. Adherence has been an issue in several hip protector studies (Howland, Peterson, & Kivell, 2006). As a result, the residents’ fear of falling may not have affected their adherence to the hip pad use in this study.
Limitations of this study include use of MDS data regarding history of falls, which may have been inaccurate or dated (Hill-Westmoreland & Gruber-Baldini, 2005). This could account for the low association of the NHFSS with prior falls. However, prospective fall data were supplemented with frequent monitoring of participants. The NHFFS was only administered to participants without moderate or severe cognitive impairment, limiting administration to only 20% of the total study sample. It is not known how the scale would perform when administered to individuals with more memory loss. However, to begin testing the instrument, the investigators chose to start with a sample with minimal cognitive impairment. Cognition is a recurring concern in measurement research with older adults, as those with cognitive impairment may not be able to accurately complete instruments (Lach, Chang, & Edwards, 2010). Further study using the NHFSS in a broader sample of nursing home residents is warranted.
Because fear of falling was not a primary outcome of the study, the inclusion of additional items on fear of falling and other related constructs was not possible. Data on additional items would have been helpful in further developing the NHFSS subscales, and inclusion of other measures would have helped evaluate the construct validity of this scale. In addition, participants’ fear of falling and NHFSS were only assessed during baseline data collection and test-retest reliability was not evaluated. Longitudinal data on fear of falling and the NHFSS would help determine changes over time and sensitivity of the measure to change for use in interventions studies. Despite these limitations, the study findings provide preliminary support for further investigation of the NHFSS.
Clinical Implications
Fear of falling was common among these nursing home residents, and many reported limiting their activities because of these concerns. As a result, fear of falling may contribute to functional decline and disability, and increased falls among nursing home residents. It is not known whether these staff caregivers identified these concerns or have concerns of their own about resident’s falling. Others have reported caregivers may overrestrict resident activities due to concerns about falling (Fitzgerald, Hadjistavropoulos, & MacNab, 2009). Current approaches to care support helping residents maintain mobility and independence in daily activities. Staff should be alert for verbal or nonverbal communications suggesting concerns about falling. The NHFSS can be used to assess resident’s falls self-efficacy. Balance and mobility issues are often related to fear of falling, so walking and exercise or physical therapy for more extensive problems should be encouraged. Addressing these issues can help older nursing home residents remain active for the best quality of life possible.
Conclusion
Given the need to explore factors influencing functional decline in nursing home residents, the NHFSS is a promising measure for exploring fall self-efficacy in the nursing home population. On first testing, the scale has acceptable reliability and validity. Additional evaluation of the NHFSS with larger and more diverse samples will help determine the utility of the measure for developing further research and interventions to address this cause of excess disability.
Footnotes
The authors declare no conflict of interest with respect to the authorship and/or publication of this manuscript.
The authors disclosed the receipt of the following financial support for the research and/or authorship of this article: This research was funded in part by NIA 2R44AG1231702. Dr. Lach’s work was supported in part by a Claire Fagin Fellowship of the John A. Hartford Foundation program Building Academic Geriatric Nursing Capacity.