Nursing Interventions to Empower Family Caregivers to Manage the Risk of Falling in Older Adults: A Scoping Review
1. Introduction
Annually, an estimated 37.3 million falls occur with sufficient severity to prompt individuals to seek healthcare services, and of these, 640,000 have fatal consequences [1]. This phenomenon is responsible for an annual loss of over 38 million years of disability-adjusted life, having a more significant impact on years of life with disability than the combined total of injuries caused by transportation, drowning, burns, and poisoning [1,2].
The fear of falling is a significant concern among older adults, as it can trigger difficulties in performing daily life activities and exacerbate anxiety, leading to reduced or absence of physical activity, thereby increasing the risk of falls [3,4,5]. Vitorino et al. [4] also concluded that risk factors associated with the fear of falling included a higher incidence of falls, female gender, age (greater age, greater fear of falling, significantly above 70 years), and poor self-perceived health status. Sedentary, decreased mobility, balance issues, living alone or with a limited social network, and polypharmacy are also risk factors for the prevalence of the fear of falling in older adults [6]. According to Huang [7], understanding the process of managing the fear of falling from the perspective of older adults is a crucial step in empowering them in fall prevention.
At the family level, falls entail direct costs related to the payment for treatments of associated injuries and indirect costs stemming from the financial loss due to time taken off work to care for their family member, psychological distress, and increased time spent in care [8,9]. These factors can lead to an increase in objective and subjective burden and a decrease in their quality of life. Socially, falls result in economic costs due to increased hospitalization time and expenses related to human resources, materials, and additional diagnostic and therapeutic procedures resulting from increased interventions [1,9].
Most older adults reside in domestic environments, where falls are most prevalent [10,11]. The family unit emerges as a pivotal element that requires empowerment to assist individuals in managing the risk of falls [12,13]. Families are the frontline observers of their daily activities and potential hazards. They are uniquely positioned to identify behavior and environmental factors contributing to falls and implement preventive measures effectively [13]. In addition, addressing the risk and fear of falling within the family context acknowledges the emotional and psychological dimensions of aging. Fear of falling can significantly impact an individual’s quality of life, leading to social withdrawal, decreased mobility, and increased dependency [14,15].
Moreover, engaging family caregivers in fall prevention interventions promotes collaboration, shared responsibility, and mutual support. Empowering family members in fall prevention interventions is crucial due to their pivotal role in the daily lives and care of their relatives [16]. As the primary support network, family members often serve as caregivers and decision makers for older adults. Therefore, equipping them with the necessary knowledge and skills to recognize and mitigate fall risks is paramount.
A study on the individual/caregiver dyad sought to understand how older adults and their caregivers perceive the fear of falling. It concluded that being cautious and careful is perceived by both parties differently. Older adults perceive it as overprotection, while caregivers see it as protective. Given these perspectives, the authors highlight the need to conduct studies on fall prevention and fear of falling interventions centered around the family [5]. Ang et al. [17] also mentioned that caregivers are aware of the risk of falls and are willing to assist their family members in preventing falls at home. For them, healthcare professionals need to involve family caregivers in their interventions and value their concerns regarding their family members’ fear of falling at home because the family plays an irreplaceable role in the lives of older individuals with a fear of falling [3].
Whether in hospital or community settings, nurses are healthcare professionals with significant and comprehensive interactions with older adults. Their presence and active involvement are essential to ensuring that older adults receive quality care, appropriate support, and preventive guidance to promote healthy aging and improved quality of life [18].
Previous reviews have primarily focused on interventions aimed at empowering individuals to prevent falls and interventions targeting professional caregivers [19,20]. However, this review marks the first examination of interventions designed to empower family members and informal caregivers. In light of this observation, this study aims to identify nursing interventions to empower family caregivers to manage the risk of falling in older adults.
2. Materials and Methods
A scoping review was chosen to achieve the study’s broad objective. Scoping reviews are well-suited to mapping and synthesizing the existing literature on a wide-ranging topic, making them an ideal choice for our research. To implement a structured and systematic approach to conducting this scoping review, we adhered to the framework established by JBI [21].
This report follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines outlined by Tricco et al. [22].
2.1. Defining and Aligning the Objective and Question
The PCC (Population, Concept, and Context) mnemonic was used to construct the research question that guided this review.
What are nursing interventions that empower family caregivers to manage the risk of falling in older adults?
2.2. Developing and Aligning the Inclusion Criteria with the Objective and Question
Following the PCC (Population, Concept, and Context) mnemonic, inclusion and exclusion criteria were established and are detailed in Table 1.
2.3. Describing the Planned Approach to Evidence Searching, Selection, Data Extraction, and Presentation of the Evidence
The leading researcher (A.S.A.) conducted the searches in electronic databases. Following the search, the researcher identified and eliminated duplicate papers, ensuring that each unique study was included only once in the review.
This researcher selected the studies with a second investigator (A.P.). Data extraction was performed by the primary researcher using a standardized instrument that was pilot tested. The other two researchers validated the data extraction table.
2.4. Searching for the Evidence
The search strategy was developed to retrieve relevant papers from electronic databases. We searched the following databases: CINAHL Complete, MEDLINE Complete, Nursing & Allied Health Collection, Comprehensive, Cochrane Central Register of Controlled Trials, MedicLatina, and Cochrane Database of Systematic Reviews.
The search was conducted on 24 June 2023, and we considered sources of evidence published in English, Portuguese, and Spanish.
The MeSH descriptors “accidental falls,” “family,” and “nurses,” in conjunction with the Boolean operator “and” were utilized to identify relevant articles.
The search strategy employed in CINAHL Complete was as follows:
S1: “Accidental falls”
S2: “Family”
S3: “Nurses”
Combined search: S1 and S2 and S3.
2.5. Selecting the Evidence
Subsequently, a two-step screening process was implemented to identify relevant papers. Initially, two researchers (A.S.A. and A.P.) independently evaluated the titles and abstracts of all identified papers. Subsequently, they independently conducted full-text assessments of potentially relevant papers to ensure complete consensus on meeting the predefined inclusion and exclusion criteria. Disagreements concerning study eligibility were resolved through constructive discussions, with input from a third researcher (A.P.N.) sought when necessary to achieve a consensus on the final selection of papers for inclusion in the scoping review.
2.6. Extracting the Evidence
A data extraction instrument for source details, characteristics, and results extraction was created to facilitate the systematic retrieval of information. This form enabled the extraction of critical data elements from each selected study: authors, publication year, study title, country, research aim, study design, and study findings.
To ensure a comprehensive analysis, the leading researcher conducted multiple readings of each selected paper, meticulously identifying and extracting the specific phrases that represented nursing interventions to empower families responsible for caring for older adults at risk of falling. Subsequently, the final extraction chart underwent a comprehensive review and discussion involving all authors.
2.7. Analysis of the Evidence
A data-driven thematic analysis was employed to examine and synthesize the collected data systematically. This analytical approach was guided by the framework developed by Braun and Clarke [23]. The primary objective of this analysis was to identify, categorize, and explore recurring themes and patterns present within the selected studies. The emerging themes were subsequently examined and interpreted within the scoping review’s objectives.
It is important to note that, by the scoping review methodology, a quality assessment or critical appraisal of the included studies was not performed, as it was not aligned with the specific objectives of this review. Instead, the focus was on mapping and synthesizing the available evidence to provide a comprehensive overview of the research related to the topic of interest.
4. Discussion
The results from this review underscore the significance of establishing a therapeutic relationship between healthcare professionals, older adults at risk of falling, and their family caregivers. The findings suggest that a strong therapeutic bond plays a crucial role in providing care. This relationship is not just a formality, but rather an essential bridge that facilitates a deeper understanding of the unique needs and concerns of older adults and their families, ultimately enabling personalized care [33].
The therapeutic relationship involves establishing trust, empathy, and mutual respect [34]. This connection serves as the cornerstone upon which effective care is built. It allows healthcare providers to explore the specific circumstances, preferences, and worries of older adults, as well as the concerns of their family caregivers. By doing so, healthcare professionals gain invaluable insights that guide the tailoring of care plans to address these individualized requirements [33].
The importance of personalized care cannot be overstated, as the fear of falling is a multifaceted issue, and its impact varies from person to person [35,36]. What works for one individual may not necessarily work for another. This is where the therapeutic relationship proves its worth. Through open and honest communication, healthcare professionals can discover the unique factors contributing to an individual’s fear of falling, whether physical limitations, past experiences, or psychological factors.
In the context of fall prevention, the therapeutic relationship acts as a two-way street. Healthcare professionals provide expertise, guidance, and security to older adults and their family caregivers. Simultaneously, they absorb the insights and perspectives of these key stakeholders, enriching their ability to deliver personalized, effective care. It nurtures a collaborative environment where older adults and their families feel heard, valued, and involved in decision making [37,38].
Effective fall prevention strategies include a multifactorial risk assessment and referral to other healthcare professionals [39,40]. As emphasized in various studies, these fundamental elements are essential for developing a comprehensive approach to reducing the risk and fear of falling. The significance of these components lies in their role in achieving a comprehensive and effective approach to fall prevention. A holistic and thorough risk assessment is pivotal in understanding the intricate factors contributing to an individual’s fall susceptibility. This assessment transcends the traditional medical examination and delves into the broader context of an individual’s life. It considers the psychological, social, and environmental factors predisposing someone to falling [40].
Numerous validated fall risk assessment tools exist for multifactorial risk assessments [41]. Extending the use of specialized fall assessment tools to home settings is not only feasible but also highly beneficial. By implementing these tools in home environments, healthcare professionals can gain insights into the unique challenges and risk factors that older adults face in their living spaces. Furthermore, conducting assessments in the home setting allows for a more personalized and targeted approach to fall prevention interventions. This proactive measure empowers older adults and their caregivers to implement practical strategies tailored to their specific needs and circumstances, reducing the risk of falls in the home environment.
A multidimensional view of an older adult’s health and well-being can be obtained by engaging professionals from various disciplines, such as physicians, nurses, physical therapists, and social workers. This interdisciplinary collaboration helps identify intrinsic and extrinsic risk factors that might be missed in a single-discipline assessment. Furthermore, referrals to other healthcare professionals extend this comprehensive approach. After identifying specific risk factors, it is vital to ensure that the individual receives the appropriate interventions and support [42,43].
This review highlights the importance of actively involving family caregivers in the care process to mitigate the risk of falling and enhance the safety of older adults within their homes. A central revelation is establishing an effective care partnership between healthcare professionals and family caregivers [24,30]. This partnership entails the exchange of information, the development of personalized care plans, and collaborative efforts to implement fall prevention strategies. Such collaboration is fundamental for adopting a holistic approach to address the risk of falling in older adults.
Moreover, the review underscores the necessity of educating and empowering family caregivers to assume an active role in fall prevention. This includes training them to identify fall risks, implement safety measures, utilize assistive devices effectively, and address the fear of falling among older adults [44].
Empowering family caregivers with knowledge and skills is pivotal in ensuring the safety of older adults [45]. It is important to explain to families that some strategies can be counterproductive, such as overly close supervision and activity restriction, and should be avoided [17]. Healthcare teams should support the implementation of safe fall prevention strategies, provide explanations, and raise awareness about the risks of specific strategies, such as excessive phone contact with family members [17].
However, it is important to note that providing information alone may not always be sufficient. Educational materials such as brochures, flyers, or books can serve as valuable supplements to reinforce the knowledge gained in educational sessions. These resources act as reference materials that family caregivers can revisit when needed, aiding in the continuous reinforcement of fall prevention strategies [46,47].
Furthermore, in an era where technology continues to evolve and seamlessly integrate into our daily lives, it becomes imperative for healthcare professionals to embrace these advances as tools for enhancing care. Notably, one study highlights educational videos as an exemplary method of leveraging technology for educational purposes [27]. These videos can effectively convey information in an engaging and accessible manner, simplifying complex concepts for better comprehension. Integrating new technologies, such as mobile apps and online platforms, presents an innovative and interactive approach to fall prevention education. These tools offer ongoing support, reminders, and resources for older adults and their family caregivers. Embracing technology enhances the effectiveness of education and aligns with the preferences of a digitally adept society [48]. However, this emphasis on education extends beyond providing general information; it is about equipping older adults and their family caregivers with the knowledge and skills necessary to identify various risk factors and make informed decisions to mitigate these risks proactively.
One key outcome of this review, as highlighted by Killingback et al. [30], is the revelation of a substantial gap in the transition from hospital-based exercise-focused fall prevention services to community-based exercise programs. This gap is evident in the perception of inadequate programs for a broad spectrum of patient groups and a clear need for increased awareness of community-based initiatives. A significant contributing factor to this challenge is the absence of established relationships and collaboration with community-run programs. This prompts questions regarding the responsible parties for supporting older individuals in sustaining their exercise regimens beyond the confines of time-limited hospital interventions.
This raises a critical concern in the healthcare landscape, where the handoff between hospital-based fall prevention services and community-run programs may not be as continuous as necessary. The lack of awareness and accessibility to suitable programs for a diverse patient population further exacerbates this challenge. It highlights the significance of establishing stronger links and collaboration between healthcare providers and community-run programs, bridging the transition gap. Parte superior do formulário
The study by Kim et al. [24] emphasized the growing need for healthcare professionals to collaborate with other professionals, particularly those from the construction industry who serve as healthcare consultants. This interprofessional collaboration has become increasingly significant as healthcare expands its horizons to embrace a more holistic approach to patient care.
The involvement of construction professionals in healthcare consulting highlights the critical need to address structural and environmental factors that can significantly impact individuals’ health and well-being. This partnership aims to create safer and more accessible living environments, especially for older adults and those with specific healthcare needs. One of the critical areas of focus in this collaboration is home modifications and renovations tailored to the unique requirements of individuals, ultimately enhancing their quality of life. These modifications may include installing safety features like grab bars, ramps, and non-slip flooring, as well as improvements to lighting and accessibility. These changes can be vital in preventing accidents, such as falls, and improving overall well-being.
While the results of this review did not specifically identify providing training and consultation to other healthcare professionals, it is crucial to underscore its significance. Training and consultation with healthcare professionals are vital to enhancing their knowledge and skills [49]. By investing in the professional development of healthcare providers, expert health professionals in fall prevention can empower them to be more proactive, adept at identifying potential risks, and skilled in implementing tailored interventions. This benefits the professionals and leads to improved patient outcomes and a healthcare system better equipped to address the complex needs of older adults at risk of falling [49,50].
Strengths and Limitations
This scoping review has some merits. One of its key strengths lies in its ability to encompass various sources, including empirical studies, literature reviews, and cross-sectional studies, providing a comprehensive overview of the topic. This breadth enables it to identify key themes, trends, and evidence gaps, shedding light on areas that have received substantial research attention and those requiring further investigation.
The review’s findings are valuable for informing decision-making processes. Policymakers, healthcare practitioners, and researchers can use the review’s insights to guide their actions. It is a rich resource that aids in making informed decisions, developing guidelines, and planning effective strategies for fall prevention and fear of falls.
However, the review also presents limitations that should be acknowledged. One of these limitations is the reliance on six databases to identify relevant studies. This approach may overlook studies on the topic that could exist in other databases or sources, potentially limiting the comprehensiveness of the review.
Furthermore, it is essential to consider the language bias, as the review confined the search to papers written in English, Portuguese, and Spanish. By doing so, the review may have inadvertently excluded relevant studies published in other languages. Another limitation is that scoping reviews, by their nature, are more focused on mapping existing literature than on assessing the effectiveness of interventions. Consequently, they may not provide a clear picture of which interventions are the most effective in fall prevention and fear of falling.
This scoping review was performed without any time restrictions. However, the number of reports was low. Therefore, we recommend further investigations into this topic.
