BMJ Open 'My independent streak may get in the way': how older adults respond to falls prevention education in hospital
BMJ Open“我的独立倾向可能会妨碍”：老年人如何应对医院的跌倒预防教育

Anne-Marie Hill, $^{1, 2}$ Jacqueline Francis-Coad, $^{2, 3}$ Terry P Haines, $^{4, 5}$ Nicholas Waldron, $^{6, 7}$
安妮·玛丽·希尔， $^{1, 2}$ 杰奎琳·弗朗西斯·科德， $^{2, 3}$ 特里·P·海恩斯， $^{4, 5}$ 尼古拉斯·沃尔德伦, $^{6, 7}$ Christopher Etherton-Beer, $^{8}$ Leon Flicker, $^{8}$ Katharine Ingram, $^{9}$ Steven M McPhail $^{10, 11}$
克里斯托弗·埃瑟顿-比尔， $^{8}$ 莱昂闪烁， $^{8}$ 凯瑟琳·英格拉姆, $^{9}$ 史蒂文·M·麦克菲尔 $^{10, 11}$

To cite: Hill A-M, FrancisCoad J, Haines TP, et al. ‘My independent streak may get in the way’: how older adults respond to falls prevention education in hospital. BMJ Open 2016;6:e012363. doi:10.1136/bmjopen-2016012363
引用：Hill AM、FrancisCoad J、Haines TP 等。 “我的独立倾向可能会妨碍”：老年人如何应对医院的跌倒预防教育。 2016 年 BMJ 公开赛；6:e012363。 doi:10.1136/bmjopen-2016012363

Prepublication history for this paper is available online. To view these files please visit the journal online (http://dx.doi.org/10.1136/ bmjopen-2016-012363).
本文的预发表历史可在线获取。要查看这些文件，请在线访问期刊 ( http://dx.doi.org/10.1136/bmjopen-2016-012363 )。

Received 21 April 2016 2016 年 4 月 21 日收到

Revised 21 June 2016 2016 年 6 月 21 日修订
Accepted 5 July 2016 2016 年 7 月 5 日接受

For numbered affiliations see end of article.
有关编号的隶属关系，请参阅文章末尾。

Correspondence to Dr Anne-Marie Hill; annemarie.hill@curtin.edu.au
通讯作者：Anne-Marie Hill 博士； annemarie.hill@curtin.edu.au

Abstract 抽象的

Objectives: The aim of the study was to determine how providing individualised falls prevention education facilitated behaviour change from the perspective of older hospital patients on rehabilitation wards and what barriers they identified to engaging in preventive strategies. Design: A prospective qualitative survey. Methods: Older patients ( $n = 757$ ) who were eligible (mini-mental state examination score>23/30) received falls prevention education while admitted to eight rehabilitation hospital wards in Western Australia. Subsequently, 610 participants were surveyed using a semistructured questionnaire to gain their response to the in-hospital education and their identified barriers to engaging in falls prevention strategies. Deductive content analysis was used to map responses against conceptual frameworks of health behaviour change and risk taking. Results: Participants who responded ( $n = 473$ ) stated that the education raised their awareness, knowledge and confidence to actively engage in falls prevention strategies, such as asking for assistance prior to mobilising. Participants’ thoughts and feelings about their recovery were the main barriers they identified to engaging in safe strategies, including feeling overconfident or desiring to be independent and thinking that staff would be delayed in providing assistance. The most common task identified as potentially leading to risk-taking behaviour was needing to use the toilet. Conclusions: Individualised education assists older hospital rehabilitation patients with good levels of cognition to engage in suitable falls prevention strategies while on the ward. Staff should engage with patients to understand their perceptions about their recovery and support patients to take an active role in planning their rehabilitation.
目的：本研究的目的是确定从康复病房老年住院患者的角度来看，提供个性化跌倒预防教育如何促进行为改变，以及他们发现采取预防策略的障碍。设计：前瞻性定性调查。方法：老年患者（ $n = 757$ ）符合资格（简易精神状态检查分数>23/30）的人在西澳大利亚州的八个康复医院病房接受跌倒预防教育。随后，使用半结构化问卷对 610 名参与者进行了调查，以了解他们对院内教育的反应以及他们发现的参与跌倒预防策略的障碍。演绎内容分析用于根据健康行为改变和冒险的概念框架绘制响应图。结果：做出回应的参与者（ $n = 473$ ）表示，教育提高了他们积极参与跌倒预防策略的意识、知识和信心，例如在行动之前寻求帮助。参与者对康复的想法和感受是他们采取安全策略的主要障碍，包括感到过度自信或渴望独立以及认为工作人员会延迟提供帮助。被认为可能导致冒险行为的最常见任务是需要使用厕所。结论：个体化教育可以帮助认知水平良好的老年医院康复患者在病房内采取适当的跌倒预防策略。工作人员应与患者接触，了解他们对康复的看法，并支持患者在规划康复过程中发挥积极作用。

INTRODUCTION 介绍

Falls in hospital settings are a substantial and costly problem with incident rates reported in Australia, Europe and the UK of between 3.2 and 17 falls per 1000 patient bed days.

^{1 - 4}

医院环境中的跌倒是一个严重且代价高昂的问题，澳大利亚、欧洲和英国报告的事故发生率为每 1000 个患者床位日 3.2 至 17 起跌倒事件。

^{1 - 4}

Strengths and limitations of this study
本研究的优点和局限性

Findings provide direct feedback from over 450 patients regarding barriers they identified to engaging in safe behaviour while admitted to hospital rehabilitation wards.
调查结果提供了超过 450 名患者的直接反馈，涉及他们在医院康复病房发现的安全行为障碍。
The study provides understanding about how falls prevention education can be provided for older hospital rehabilitation patients who have adequate levels of cognition, using a theoretical framework of health behaviour change.
该研究利用健康行为改变的理论框架，让人们了解如何为具有足够认知水平的老年医院康复患者提供跌倒预防教育。
Findings are from one state health setting and may not be generalisable to different health settings.
研究结果来自一个州的卫生环境，可能无法推广到不同的卫生环境。

Up to

30 %

of these falls can result in physical injury, and

\sim 2 %

result in fractures.

^{1}^{3}

Older patients in geriatric or rehabilitation wards are at increased risk of falls compared to other patient populations.

^{24}

Multifactorial strategies have been found to have some effect in reducing in-hospital falls, but there is uncertainty about the type and amount of intervention components that should be provided.

^{5}^{6}

Previous randomised controlled trials (RCT) testing individual hospital fall prevention interventions have found that low-low beds and bed alarms do not reduce falls.

^{7 - 9}

最多

30 %

这些跌倒可能会导致身体伤害，并且

\sim 2 %

导致骨折。

^{1}^{3}

与其他患者群体相比，老年病房或康复病房的老年患者跌倒的风险更高。

^{24}

研究发现，多因素策略对减少院内跌倒有一定效果，但应提供的干预措施的类型和数量尚不确定。

^{5}^{6}

之前测试个别医院跌倒预防干预措施的随机对照试验 (RCT) 发现，低矮床和床警报器并不能减少跌倒。

^{7 - 9}

In hospital settings, falls most often occur when patients attempt to mobilise, particularly when mobilising to the toilet.

^{10 - 12}

Additionally, large studies have demonstrated that over

80 %

of falls are unwitnessed, meaning patients tend to fall when no staff are in attendance.

^{13} 14

This suggests that older patients may be attempting to engage in mobility tasks without appropriate assistance or mobility aids, which place them at an unnecessary high risk of falling.
在医院环境中，跌倒最常发生在患者试图活动时，尤其是上厕所时。

^{10 - 12}

此外，大型研究表明，超过

80 %

的跌倒是无人目睹的，这意味着患者在没有工作人员在场的情况下很容易跌倒。

^{13} 14

这表明老年患者可能在没有适当帮助或行动辅助工具的情况下尝试从事行动任务，这使他们面临不必要的高跌倒风险。

Older patients recovering from illness or injury in hospital benefit from engaging in rehabilitation with the goal of regaining their premorbid level of functional mobility. This typically requires them to achieve
在医院从疾病或受伤中恢复的老年患者受益于康复，目标是恢复病前的功能活动水平。这通常要求他们实现
gradual but safe progression of functional mobility tasks without placing them at excessive risk of falling. Previous qualitative work has identified factors leading older adults to take risks that could contribute to them falling while in hospital.

^{15}

Factors found to influence older patients’ propensity to engage in risk-taking behaviours while in hospital included their willingness to ask for help, desire to test their physical boundaries, communication failures between older patients and health professionals caring for them and delayed provision of help. Therefore, finding a way to provide falls prevention education to older patients undergoing rehabilitation which would reduce unnecessary risk taking was required.
逐步但安全地进行功能性活动任务，而不会使他们面临过高的跌倒风险。之前的定性研究已经确定了导致老年人冒险的因素，这些因素可能导致他们在医院期间跌倒。

^{15}

研究发现，影响老年患者在医院期间采取冒险行为倾向的因素包括他们寻求帮助的意愿、测试自己身体界限的愿望、老年患者和照顾他们的医疗专业人员之间的沟通失败以及延迟提供帮助。因此，需要找到一种方法为接受康复治疗的老年患者提供跌倒预防教育，以减少不必要的冒险行为。

The authors of the present study recently conducted an RCT that evaluated providing individualised falls prevention education to older hospital patients in rehabilitation wards, called the Safe Recovery programme:

^{16}

the programme was designed and delivered using principles of health behaviour change and a sound pedagogical structure.

^{17 - 20}

Educators also provided training to staff to support the programme. Feedback obtained after they delivered the programme was that the education facilitated mutual understanding between staff and patients, which assisted patients to engage in falls prevention behaviours on the ward.

^{21}

The intervention reduced falls on aged care hospital rehabilitation wards by

40 %

and injury resulting from falls by

35 % .^{22}

The reduction in falls and injurious falls rates was observed across the whole ward and did not only occur in the subgroup of patients with adequate cognition who directly received the education. This large multicentre trial which provided education to over 750 patients provided a valuable opportunity to engage directly with older patients to gain their perspectives about how health education can work to effect a change in older adults’ health behaviour, namely engagement in falls prevention strategies while undergoing rehabilitation in hospital. This could assist to facilitate further translation of the intervention into clinical practice.
本研究的作者最近进行了一项随机对照试验，评估为康复病房的老年患者提供个性化跌倒预防教育，称为安全康复计划：

^{16}

该计划的设计和实施采用了健康行为改变原则和健全的教学结构。

^{17 - 20}

教育工作者还为工作人员提供培训以支持该计划。项目实施后得到的反馈是，教育促进了工作人员和患者之间的相互理解，帮助患者在病房内进行预防跌倒的行为。

^{21}

该干预措施减少了老年护理医院康复病房的跌倒次数

40 %

以及跌倒造成的伤害

35 % .^{22}

在整个病房观察到跌倒和伤害性跌倒发生率的下降，并且不仅仅发生在直接接受教育的认知能力良好的患者亚组中。这项大型多中心试验为超过 750 名患者提供了教育，提供了直接与老年患者接触的宝贵机会，以了解他们对健康教育如何影响老年人健康行为改变的看法，即在接受跌倒预防策略时参与其中在医院康复。这有助于促进干预措施进一步转化为临床实践。

Other studies have examined falls epidemiology using hospital incident reports which contain staff’s observations and reports about how individual falls occurred on their hospital wards.

^{4}^{10}^{11}

Qualitative studies have also interviewed patients and staff regarding why they think falls could occur on hospital wards.

^{1523}^{24}

However, the patients in the present trial were a unique cohort as they had been provided with effective, pedagogically sound education about falls and falls prevention on hospital wards. Therefore, these older hospital patients were well positioned to provide feedback about how falls education in hospitals is received by older patients, and an informed perspective about barriers that they perceived could prevent them from engaging in effective falls prevention strategies.
其他研究利用医院事件报告来研究跌倒流行病学，其中包含工作人员的观察结果以及有关医院病房中个人跌倒发生情况的报告。

^{4}^{10}^{11}

定性研究还采访了患者和工作人员，了解他们认为医院病房可能发生跌倒的原因。

^{1523}^{24}

然而，本试验中的患者是一个独特的群体，因为他们在医院病房接受过有关跌倒和跌倒预防的有效、教学合理的教育。因此，这些老年医院患者能够很好地提供关于老年患者如何接受医院跌倒教育的反馈，以及他们认为可能阻止他们采取有效跌倒预防策略的障碍的知情观点。
The purpose of the study was
该研究的目的是

To determine what older hospital patients’, who were on rehabilitation wards, responses were to being provided with individualised falls prevention education;
确定康复病房的老年医院患者对个性化跌倒预防教育的反应；
To identify perceived barriers that hindered older patients who were on rehabilitation wards from engaging in falls prevention strategies while in hospital.
找出阻碍康复病房老年患者在医院期间采取跌倒预防策略的明显障碍。

METHODS 方法

Ethics 伦理
This study was conducted as part of a cluster randomised trial that took place on eight hospital rehabilitation wards. The trial was approved by The University of Notre Dame Australia and The Sir Charles Gairdner Group Human Research Ethics Committees (numbers 2012_141 and 012069F), and a waiver of consent was obtained for obtaining individual patient’s or staff’s consent. All participant data collected from the posteducation survey was de-identified and grouped across all sites prior to analysis.
这项研究是在八个医院康复病房进行的整群随机试验的一部分。该试验得到了澳大利亚圣母大学和查尔斯·盖尔德纳爵士集团人类研究伦理委员会（编号2012_141和012069F）的批准，并获得了患者或工作人员个人同意的弃权。在分析之前，从教育后调查中收集的所有参与者数据都经过去识别化处理并在所有站点进行分组。

Design 设计

A prospective qualitative survey informing the process evaluation of a cluster RCT was undertaken. The study took a descriptive and explanatory approach with qualitative data being collected from a cohort of patients who received the intervention within the larger RCT. These patients were admitted to hospital rehabilitation wards which delivered the education intervention. The protocol and trial results have been described elsewhere.

^{1622}

进行了一项前瞻性定性调查，为整群随机对照试验的过程评估提供信息。该研究采用描述性和解释性的方法，从在大型随机对照试验中接受干预的一组患者中收集定性数据。这些患者被送往医院康复病房接受教育干预。方案和试验结果已在其他地方描述。

^{1622}

Participants and setting 参加者及设置

Participants

(n = 757)

were older patients who were admitted to one of eight hospital rehabilitation wards that participated in a cluster RCT in Western Australia in 2013.

^{22}

The wards were situated in hospitals that provide acute and rehabilitation care, and ranged from wards that provided short-stay geriatric evaluation and management to those that provided geriatric rehabilitation. There were 1623 admissions to intervention wards. Of those,

56 %

(914) patients were deemed eligible, based on a cognitive screen, to receive the education, and 757

(46.6 %)

received the education.

^{22}

These patients received the education because they were screened as having levels of cognition where they could potentially benefit from receiving education, assessed using the minimental state examination

(> 23 / 30)

or the abbreviated mental test score

(> 7 / 10) .^{25}^{26}

A more detailed description of the cohort has been provided previously.

^{22}

Briefly, these participants (mean age

81.4 \pm 9.3

years and median (IQR) LOS 12 days (7-21)) were admitted to the participating wards for ongoing rehabilitation. Admission diagnoses included orthopaedic conditions such as fractures, cardiac and respiratory conditions and general functional decline.
参加者

(n = 757)

是 2013 年参加西澳大利亚集群随机对照试验的八个医院康复病房之一收治的老年患者。

^{22}

这些病房位于提供急症和康复护理的医院内，范围从提供短期老年病评估和管理的病房到提供老年康复的病房。共有 1623 人入住干预病房。其中，

56 %

(914) 根据认知筛查，患者被认为有资格接受教育，而 757

(46.6 %)

接受了教育。

^{22}

这些患者接受了教育，因为他们被筛选为具有可能从接受教育中受益的认知水平，并使用简易精神状态检查进行评估

(> 23 / 30)

或简短的心理测试分数

(> 7 / 10) .^{25}^{26}

之前已经提供了该队列的更详细描述。

^{22}

简而言之，这些参与者（平均年龄

81.4 \pm 9.3

年和中位 (IQR) LOS 12 天 (7-21)) 被纳入参与病房进行持续康复。入院诊断包括骨科疾病，如骨折、心脏和呼吸系统疾病以及一般功能衰退。

Data collection and procedure
数据收集和程序

Participants who were admitted to the intervention wards and screened as being eligible to receive the intervention were provided with the education called the Safe Recovery programme, as soon as was practical after
进入干预病房并被筛选为有资格接受干预的参与者在可行后立即接受了名为“安全康复计划”的教育。
admission in addition to their usual care. This education programme has been described extensively elsewhere.

^{18}^{19}

In summary, participants viewed a DVD and were provided with a workbook, both of which provided information about the epidemiology of falls and falls prevention in hospitals. Trained educators subsequently conducted follow-up education sessions for each participant to personalise the education.
除了平时的护理外，还需要住院治疗。该教育计划已在其他地方进行了广泛描述。

^{18}^{19}

总之，参与者观看了一张 DVD 并获得了一本工作手册，两者都提供了有关跌倒流行病学和医院跌倒预防的信息。训练有素的教育工作者随后为每个参与者进行后续教育课程，以实现个性化教育。

The education programme provided participants with a three-step message: (1) know if you need help, (2) ask for help and (3) wait for help. The educator facilitated participants to develop a personalised action plan consisting of strategies that allowed them to engage safely in required mobility tasks on the ward and work cooperatively with staff, such as by ringing the bell if they required help. The intervention was delivered to all eligible older patients admitted to the intervention wards. The educators also provided the hospital ward staff with feedback about the programme, which alerted the staff to support older patients to engage in effective strategies that would maintain safe mobility. Patients admitted to control wards continued to receive their usual care.
该教育计划向参与者提供了三步信息：(1) 了解您是否需要帮助，(2) 寻求帮助，(3) 等待帮助。教育工作者帮助参与者制定个性化的行动计划，其中包括使他们能够安全地参与病房所需的移动任务并与工作人员合作的策略，例如在需要帮助时按铃。干预措施适用于入住干预病房的所有符合条件的老年患者。教育工作者还向医院病房工作人员提供了有关该计划的反馈，该计划提醒工作人员支持老年患者采取有效的策略来保持安全活动。入住对照病房的患者继续接受常规护理。

The educators collected data for the present study as part of a broader face-to-face survey of participants after they completed the education programme. Usually, the survey was administered

2 - 3

days after the final session, but participants could still receive extra education sessions after the survey if the patient or educator thought it was required. As part of this survey, participants were asked to list the three key strategies that formed part of their action plan and to nominate the strategy that they thought would be most effective in reducing their risk of falls. They were then asked an open-ended question: ‘is there anything that could stop you from (naming participant’s nominated strategy)?’, whereby the participant could identify any barriers that they thought would prevent them undertaking their planned falls prevention strategies. Subsequently, the second open-ended question asked participants ‘is there anything you would like to share with the educator team regarding the program?’. Participants’ responses to these two questions were recorded verbatim. At the close of the face-to-face survey, the responses were read back to the participant to clarify and confirm meaning.
教育工作者为本研究收集了数据，作为对参与者完成教育计划后更广泛的面对面调查的一部分。通常，调查是进行

2 - 3

在最后一次会议后几天，但如果患者或教育者认为有必要，参与者仍然可以在调查后接受额外的教育课程。作为本次调查的一部分，参与者被要求列出构成其行动计划一部分的三个关键策略，并提名他们认为最有效降低跌倒风险的策略。然后他们被问到一个开放式问题：“有什么可以阻止你（说出参与者指定的策略）吗？”，参与者可以识别他们认为会阻止他们执行计划的跌倒预防策略的任何障碍。随后，第二个开放式问题询问参与者“关于该计划，您有什么想与教育团队分享的吗？”。参与者对这两个问题的回答被逐字记录。在面对面调查结束时，将回复读回给参与者以澄清和确认含义。

Analysis 分析

Content analysis was undertaken using a deductive approach.

^{27}

All verbatim responses from participants were de-identified, extracted from the surveys and organised using Microsoft Excel prior to entry into NVivo (V. 10 for Windows QSR International, NVivo V. 10 Qualitative data analysis software, 2012) for further management. Two researchers (A-MH and JF-C) independently read through the data several times prior to development of a categorisation matrix, using the constructs of the health belief model (HBM) which had been used to develop and evaluate the education programme.

^{17}^{20}

The HBM conceptualises that raising awareness of the threat or susceptibility to a condition and providing knowledge about the recommended behaviours to reduce the threat allow an individual to weigh up the benefits and barriers to engaging in the health behaviour concerned. Consequently, given suitable cues to action and having the self-efficacy or confidence and motivation, the individual will engage in the desired health behaviour. Codes therefore corresponded with the HBM constructs of awareness, knowledge, confidence and motivation and modifying factors. This conceptual framework applied to falls prevention is presented in figure 1,28 and its applicability to the education programme is presented in table 1. The coding process was based on examining the words and phrases that participants used and coding them according to the identified categories; therefore, a phrase such as ‘helping to make me aware’ would be coded as awareness. Where data provided patterns of categorical responses, frequency counts were also undertaken. Coded data from the categorisation matrix were then grouped under higher order headings to reduce the number of categories, through the collapse of like and unlike categories. The abstraction process involved applying content-specific words to each category. Subcategories with similarities were then described using a generic category. A third researcher (SMM) who was not involved in data collection or coding was invited to scrutinise the coding and arbitrate any differences.
使用演绎方法进行内容分析。

^{27}

参与者的所有逐字回复均经过去识别化处理，从调查中提取并在进入 NVivo（V.10 for Windows QSR International、NVivo V.10 定性数据分析软件，2012）之前使用 Microsoft Excel 进行组织以进行进一步管理。两名研究人员（A-MH 和 JF-C）在开发分类矩阵之前，使用已用于开发和评估教育计划的健康信念模型 (HBM) 的结构，独立地多次阅读数据。

^{17}^{20}

HBM 的概念是，提高对某种疾病的威胁或易感性的认识，并提供有关减少威胁的建议行为的知识，使个人能够权衡参与相关健康行为的好处和障碍。因此，给予适当的行动提示并具有自我效能或信心和动力，个人将采取所需的健康行为。因此，代码与意识、知识、信心、动机和修改因素的 HBM 结构相对应。这个应用于跌倒预防的概念框架如图 1,28 所示，其对教育计划的适用性如表 1 所示。编码过程基于检查参与者使用的单词和短语，并根据已确定的类别对其进行编码；因此，诸如“帮助让我意识到”之类的短语将被编码为意识。如果数据提供了分类响应模式，则还进行频率计数。然后，来自分类矩阵的编码数据被分组在更高阶的标题下，以通过折叠相似和不同类别来减少类别数量。抽象过程涉及将特定于内容的单词应用于每个类别。然后使用通用类别来描述具有相似性的子类别。第三位未参与数据收集或编码的研究人员 (SMM) 被邀请仔细检查编码并仲裁任何差异。

The nature of the education was that it facilitated strategies whereby patients could reduce their risk of falls. Therefore, analysis of the barriers that patients identified was based on a conceptual framework that had been constructed from a previous study, which interviewed patients and staff to understand why older adults might take risks in hospital that could lead to falls.

^{15}

The framework conceptualises that basic elements of risk taking can be described within three broad constructs: the older patient, the environment and the task to be attempted. The nature of risk taking itself is described within two categories: voluntary, where the patients feel they have a choice as to whether they attempt to perform the task, and enforced, where the older patient feels there is no alternative but to attempt to perform the task. Voluntary risk taking is further conceptualised to be either informed, where an older patient decides to take a risk when aware of the risks involved, or mal-informed, where the patient takes a risk but is not fully aware of the risks involved. The final review of analyses was conducted by the three researchers who met and viewed the coded results against the conceptual frameworks. All three researchers discussed the subcategories, generic categories and the conceptual frameworks to reach consensus.
教育的本质是它促进了患者减少跌倒风险的策略。因此，对患者发现的障碍的分析是基于先前研究构建的概念框架，该研究采访了患者和工作人员，以了解为什么老年人可能会在医院冒可能导致跌倒的风险。

^{15}

该框架的概念是，冒险的基本要素可以用三个广泛的结构来描述：老年患者、环境和要尝试的任务。冒险本身的性质分为两类：自愿的，即患者认为他们可以选择是否尝试执行任务；强制的，即老年患者认为除了尝试执行任务之外别无选择。任务。自愿冒险被进一步概念化为要么是知情的，即老年患者在意识到所涉及的风险时决定承担风险，要么是错误告知的，即患者承担了风险但不完全意识到所涉及的风险。最终的分析审查是由三名研究人员进行的，他们会见并根据概念框架查看编码结果。三位研究人员讨论了子类别、通用类别和概念框架，以达成共识。

RESULTS 结果

During the main trial, 757 (

91 %

) of the eligible participants received the education programme. Of these
第757章

91 %

) 的合格参与者接受了教育计划。其中

看法/信念/知识

Perceptions /

Beliefs/

Knowledge

观念/信念的整合

Integration of

Perceptions / Beliefs

Action 行动

健康结果

Health

outcome

Figure 1 Constructs of the HBM framework applied to the patient education programme. Adapted from Hill et al.

^{28} HBM

, health belief model.
图 1 应用于患者教育计划的 HBM 框架的构建。改编自希尔等人。

^{28} HBM

、健康信念模型。

Table 1 Constructs of the HBM applied for providing individualised falls prevention education to older patients in hospital
表1 HBM应用于为住院老年患者提供个体化跌倒预防教育的构建
HBM construct HBM构建体

Perceived susceptibility 感知的易感性

Perceived severity Perceived benefits
感知的严重性感知的好处

Perceived barriers 感知到的障碍

Cues to action 行动线索

Self-efficacy 自我效能感

Definition 定义

One’s opinion of his/her chances of getting a condition
一个人对其患病机会的看法

One’s opinion of how serious a condition and its sequelae are
一个人对病情及其后遗症严重程度的看法
One’s opinion of the efficacy of the advised action to reduce risk or seriousness of impact
对所建议的降低风险或影响严重性的行动的有效性的看法

One’s opinion of the tangible and psychological costs of the advised action
对建议行动的有形和心理成本的看法

Strategies to activate ‘readiness’ to change
激活“准备好”改变的策略

Confidence in one’s ability to take action, ie, engage in falls prevention strategies, motivation to take action
对自己采取行动的能力的信心，即参与跌倒预防策略、采取行动的动力

Application to falls prevention education
在跌倒预防教育中的应用

Personalise risk of falls based on person’s mobility or behaviour.
根据人的活动能力或行为个性化跌倒风险。
Raise perceived susceptibility, awareness of falls if too low, provide information about when and where falls occur in hospital
如果太低，则提高对跌倒的感知易感性和意识，提供有关在医院发生跌倒的时间和地点的信息
Specify consequences of the risk of falls and injury that results from falls
明确跌倒风险和跌倒造成的伤害的后果
Define action to take: how, where and when; to reduce falls risk while a patient on hospital ward, clarify the positive effects on mobility and safety to be expected Identify and reduce barriers to engaging in falls risk reduction strategies through reassurance, incentives, support from staff and family Provide how-to information about the strategies, promote awareness, reminders of the cues to action (such as keeping bell in reach, communicate with staff about abilities and rehabilitation process)
定义要采取的行动：如何、何地和何时；降低患者在医院病房时的跌倒风险，阐明预期对活动性和安全性的积极影响通过安抚、激励、工作人员和家人的支持，识别并减少参与降低跌倒风险策略的障碍提供有关跌倒风险降低策略的操作方法信息策略、提高意识、提醒行动提示（例如将铃放在触手可及的地方、与工作人员就能力和康复过程进行沟通）
Emphasise positive and achievable nature of required actions. Training and support for performing falls prevention behaviours, with graded feedback, staff, educator, family provide positive feedback on actions taken
强调所需行动的积极性和可实现性。对预防跌倒行为进行培训和支持，并提供分级反馈，工作人员、教育者、家人对所采取的行动提供积极的反馈
HBM, health belief model.
HBM，健康信念模型。
participants, 704 (92.3%) completed a written action plan, where participants were assisted to complete a written action plan that consisted of a number of goals.

^{22}

Goals took the form of practical strategies and were related to each participant’s individual functional mobility in the context of their medical condition and
在参与者中，704 名（92.3%）完成了书面行动计划，参与者在协助下完成了包含多个目标的书面行动计划。

^{22}

目标采取实用策略的形式，并与每个参与者在其医疗状况和健康状况下的个人功能活动能力相关。
were based on the behaviour modification and motivation messages contained in the Safe Recovery programme. Examples of frequently set goals by participants who were able to independently complete some or all of their mobility tasks were as follows: (1) use prescribed walking aid when walking and (2) get up slowly and check for dizziness before walking. Examples of frequently set goals by participants who required assistance of staff to mobilise were as follows: (1) keep the call-bell in reach at all times and (2) ask for help to get from the chair to the bed. Participants in total set 1643 goals for their action plan with a median of 2

(1 - 3)

goals per participant.

^{22}

是基于安全康复计划中包含的行为矫正和动机信息。能够独立完成部分或全部行动任务的参与者经常设定的目标示例如下：（1）行走时使用规定的助行器；（2）缓慢起身，并在行走前检查是否头晕。需要工作人员协助进行动员的参与者经常设定的目标示例如下：(1) 始终将呼叫铃放在触手可及的地方；(2) 寻求帮助以从椅子到床上。参与者总共为其行动计划设定了 1643 个目标，中位数为 2

(1 - 3)

每个参与者的目标。

^{22}

After the education was delivered, 610 (80.6%) participants completed the post-education survey. The most frequent reason for not undertaking the survey was unanticipated discharge prior to the survey being administered. Of these participants,

473 (77.5 %)

provided a response to the open-ended question regarding their perception of the education programme and 319 (

52.3 %

) provided a response about barriers they thought could prevent them from engaging in their planned safety behaviours on the ward. The most frequent reason for not providing a response about barriers (

n = 158 (25.9 %)

) was that the participant needed to engage in other wards tasks and could not finish the survey.
教育结束后，610 名（80.6%）参与者完成了教育后调查。不进行调查的最常见原因是在进行调查之前意外出院。在这些参与者中，

473 (77.5 %)

第 319 章

52.3 %

）对他们认为可能阻止他们在病房进行计划的安全行为的障碍做出了回应。不提供有关障碍的回应的最常见原因（

n = 158 (25.9 %)

）的原因是参加者需要从事其他病房的工作，无法完成调查。

The abstraction process identified subcategories that explained participants’ responses to the education (presented in table 2). These subcategories were then mapped against the conceptual framework of the HBM (table 2).
抽象过程确定了解释参与者对教育的反应的子类别（如表 2 所示）。然后根据 HBM 的概念框架映射这些子类别（表 2）。
Participants stated that the education “…makes you aware of what can happen… (p. 602)” and was “…excellent for increasing awareness; highlights need for safety (p. 198),” while another participant demonstrated raised awareness of thinking about falls prevention, stating “…I hope this will help keep me thinking before moving and only thinking about moving when I am moving (p. 109).”
参与者表示，教育“……让你意识到会发生什么……（第 602 页）”并且“……非常有助于提高意识；强调安全的必要性（第 198 页）”，而另一位参与者则表现出对预防跌倒的意识有所提高，并表示“……我希望这将有助于让我在移动前思考，并且只在移动时才考虑移动（第 109 页） ”。

Participants consistently reported that they gained knowledge from the education programme which was described as “…useful and interesting… (p. 189)” and “…very informative, told me what I needed to know (p. 6).” Participants also reflected that the education programme gave them the right amount of confidence, stating that it was “…helpful, makes you feel confident but not over-confident ( p. 169).” Some participants specifically reported that they gained motivation and intended to engage in their planned falls prevention strategies such as “…this was very interesting and helpful and I will now speak up and ask more (p. 87).”
参与者一致报告说，他们从教育计划中获得了知识，该计划被描述为“……有用且有趣……（第 189 页）”和“……信息非常丰富，告诉我需要知道什么（第 6 页）”。参与者还反映，教育计划给了他们适当的信心，并表示它“……有帮助，让你感到自信，但不会过度自信（第 169 页）”。一些参与者特别报告说，他们获得了动力，并打算参与计划中的跌倒预防策略，例如“……这非常有趣且有帮助，我现在要大声说出来并询问更多信息（第 87 页）。”

Participants also appeared to be motivated to engage with the programme because of the underlying programme design, with many stating that they “…thought the DVD was very good, well produced (p. 548)” and “…I learnt a lot from the DVD-very educational (p. 423).” They also commented on the appeal of the concrete, practical nature of the programme with one participant stating “…glad it’s been raised, very practical, very wise move to present this information (p. 163).” A subgroup of older participants suggested that the education programme should be delivered to other older hospital patients as broadly as possible:
由于基本的程序设计，参与者似乎也有动力参与该程序，许多人表示他们“……认为 DVD 非常好，制作精良（第 548 页）”并且“……我从 DVD 中学到了很多东西” -非常有教育意义（第423页）。”他们还评论了该计划的具体、实用性质的吸引力，一位参与者表示“……很高兴提出这一点，这是非常实用、非常明智的举措，展示了这一信息（第 163 页）。”老年参与者的一个小组建议，应尽可能广泛地向其他老年医院患者提供教育计划：
“Should be put out there more. Lots of people don’t realise these things. It’s quite correct, made me more aware, didn’t realise things could happen (p.394).”
“应该多放在那里。很多人并没有意识到这些事情。这是非常正确的，让我更加意识到，没有意识到事情可能会发生（p.394）。”

A few participants felt that the education programme was of “…no benefit as just common sense… (p. 556)” with one participant stating that it was “common sense, a waste of time for me personally… (p.331).” Some participants responded that choice to actively respond to the education was important, “…it’s easier to make your own mind up when you what the results can be… (p. 12).” A few participants felt that maintaining one’s own independence was paramount:
一些参与者认为教育计划“……没有任何好处，只是常识……（第 556 页）”，一名参与者表示，这是“常识，对我个人来说是浪费时间……（第 331 页）”。 ”一些参与者回应说，选择积极回应教育很重要，“……当你知道结果是什么时，你会更容易做出自己的决定……（第 12 页）。”一些参与者认为保持自己的独立性至关重要：
“I know, I know what you guys think I should be doing and I do understand but sometimes you just have to judge things yourself (p. 78).”
“我知道，我知道你们认为我应该做什么，我也理解，但有时你必须自己判断事情（第 78 页）。”

Participants’ diverse range of responses indicated that the individualised nature of the programme helped them to develop tailored strategies which were relevant to them personally, demonstrating that the programme was able to be effectively delivered despite the heterogeneous clinical settings. For example, one participant responded that the education made them realise that “…(I) need to keep in mind that other people need help too, so be patient, not think you are the only one… (p. 435)” indicating gain in knowledge of ward procedure. Another participant gained knowledge specific to their own behaviour on the ward, stating “…it did make me understand why the nurses are always after me not to walk in my socks (p.80).”
参与者的不同反应表明，该计划的个性化性质帮助他们制定了与他们个人相关的定制策略，表明尽管临床环境不同，该计划仍能够有效实施。例如，一位参与者回应说，教育让他们意识到“......（我）需要记住其他人也需要帮助，所以要有耐心，不要认为你是唯一的......（第435页）”表明收获了解病房程序。另一位参与者获得了有关他们自己在病房行为的具体知识，并表示“……这确实让我明白为什么护士总是追着我不要穿袜子走路（第 80 页）。”

Participants’ responses indicated that the nature of the education programme was effective in raising most participants’ awareness about falls prevention, addressing gaps in their personal knowledge and allowing them to identify previously unrecognised risks of falling, while raising their motivation to engage in safe behaviour on the ward. When participants’ responses to receiving the education programme were examined as a whole, these generic categories were able to be described by one main category of ‘active engagement’. Most participants engaged with the education in a positive manner and responded actively to complete their falls prevention plan. Figure 2 summarises participants’ responses within the conceptual framework of the HBM. This represented a conceptualisation of how the education programme could be effective in assisting participants to engage in the falls prevention strategies they had planned.
参与者的反应表明，教育计划的性质有效地提高了大多数参与者对预防跌倒的认识，弥补了他们个人知识的差距，使他们能够识别以前未认识到的跌倒风险，同时提高了他们采取安全行为的动力。病房。当参与者对接受教育计划的反应作为一个整体进行审查时，这些通用类别可以用“积极参与”这一主要类别来描述。大多数参与者积极参与教育并积极响应，完成预防跌倒计划。图 2 总结了参与者在 HBM 概念框架内的反应。这代表了教育计划如何有效帮助参与者参与他们计划的跌倒预防策略的概念化。

Barriers identified by participants to engaging in planned falls prevention strategies are presented in table 3. The most frequent barriers identified to engaging in safe falls prevention behaviours were their own thoughts and feelings about their recovery

(n = 205

(64.3%)), in
表 3 列出了参与者发现的参与计划跌倒预防策略的障碍。参与安全跌倒预防行为的最常见障碍是他们自己对康复的想法和感受

(n = 205

(64.3%)), 在

Table 2 Participants’ responses to the education programme
表 2 参与者对教育计划的反应

频率，

N = 473

(100%)

Frequency,

N = 473

(100%)

HBM codes HBM 代码

Participants' survey responses
参与者的调查回应

Subcategory 子类别

Generic category 通用类别

92 (19.4)

Awareness 意识

对跌倒和受伤风险的感知敏感性

Perceived

susceptibility of risk of

falls and injury

40 (8.5)

“……让我更加意识到跌倒风险……（第 239 页）”，“……让我认识到跌倒的风险……（第 550 页）”

"...Made me more aware of falls risk...

(p. 239)," "...opened my eyes to the risk

of falls... (p.550)"

提高跌倒风险意识

Increased awareness

of falls risk

31 (6.5)

“...将其放在您的脑海中...（第 186 页）”，“...康复期间的安全很重要...（第 14 页）”

"...Puts it at the front of your mind...

(p. 186)," "...It is important to be safe

while getting well... (p. 14)"

反思需要安全

Reflection about

needing to be safe

21 (4.4)

“……这让我意识到我需要思考我需要做什么，直到我真正恢复正常……（第44页），”“……我之前像个白痴一样忽略了它……（第 371 页）”

"...It makes me realise I need to think

about what I need to do until I am really

back to normal... (p. 44)," "...I ignored it

before like an idiot... (p.371)"

意识到需要帮助/需要改变自己的行为

Realised needs help/

will need to modify own

behaviour

164 (34.7)

Knowledge 知识

跌倒及跌倒预防知识

Knowledge about falls

and falls prevention

52 (11)

“...这是向所有患者提供的好信息...（第 131 页）”，“...有用的信息...（第 337 页）”

"... This was good information to give to

all patients... (p. 131)," "...helpful

information... (p. 337)"

Informative 信息丰富

49 (10.4)

“...有用，涵盖了所有要点...（第 187 页）”，“...非常有用的程序...（第 215 页）”

"...Useful, covered all points... (p. 187),"

"...very helpful program... (p. 215)"

Useful/helpful 有用/有帮助

44 (9.3)

“……常识，很好地将理论付诸实践……（第 584 页）”，“……都是好的常识……（第 64 页）”

"...Common sense, good to put theory

into practice... (p. 584)," "...all good

common sense... (p. 64)"

Common sense 常识

19 (4)

“...发现它非常有趣...”，“有趣：易于理解...（第 146 页）”

"...Found it very interesting...,"

"interesting: easy to follow... (p. 146)"

Interesting 有趣的

136 (28.8)

Motivation 动机

参与跌倒预防策略的动机

Motivation to engage

in falls prevention

strategies

41 (8.7)

“...这真是太棒了...（第 626 页），”“...非常有用的程序...（第 399 页）”

"...Its darn good... (p. 626)," "...very

helpful program... (p. 399)"

良好的计划 - 计划结束后感觉积极

Good programme-

feeling positive after

programme

59 (12.5)

“...喜欢 DVD，非常清晰...（第 565 页）”，“...与室友一起观看 DVD 非常喜欢...（第 404 页）”

"...Enjoyed the DVD, very clear...

(p. 565)," "...watched DVD together with

roommate enjoyed it very much...

(p. 404)"

欣赏，优秀的DVD

Enjoyment, excellent

DVD

36 (7.6)

“......很好，会让我在尝试自己去之前三思而后行......（第516页），”“......会小心并寻求帮助......（第306页）”

"...Good, will make me think twice before

attempting to go on my own... (p. 516),"

"...will be careful and get help... (p.306)"

有动力改变行为/赋予权力

Motivated to change

behaviour/empowering

35 (7.4)

Confidence 信心

有信心参与跌倒预防策略

Confidence to engage

in falls prevention

strategies

24 (5.1)

“它鼓励你防止跌倒......（第 425 页）”，“帮助我在需要帮助时感觉更好......（第 96 页）”

"It encouraged you to prevent falls...

(p. 425)," "helps make me feel better

about needing help... (p.96)"

Encouraging/reassuring 鼓励/安慰

11 (2.3)

“……这真的会帮助我感到自信……（第 134 页）”，“……这让我更有信心与理疗师谈论我能做什么和不能做什么……（第 134 页）” 102）”

"...This will really help me feel

confident... (p. 134)," "...it makes me

more confident to speak to the physio

about what I can and can't do... (p. 102)"

Gives confidence 给人信心

46 (9.7)

修改因素

Modifying

factors

修改有利于采取行动的因素

Modifying factors that

facilitate taking action

33 (7)

“……我关心我的丈夫（所以）所有这些信息都非常明显，我意识到它也适用于我……（第 111 页）”

" ...I care for my husband (so) all this

information is really obvious and I realise

it applies to me as well... (p. 111)"

个人/社会情况

Personal/social

circumstances

13 (2.7)

“……让我想起以前的学习……以前去过跌倒诊所……（第 418 页）”

"...Reminded me of previous learning...

have been to falls clinic before...

(p. 418)"

Prior learning 之前的学习

"Frequency, N=473 (100%)" HBM codes Participants' survey responses Subcategory Generic category 92 (19.4) Awareness "Perceived susceptibility of risk of falls and injury" 40(8.5) ""...Made me more aware of falls risk... (p. 239)," "...opened my eyes to the risk of falls... (p.550)"" "Increased awareness of falls risk" 31 (6.5) ""...Puts it at the front of your mind... (p. 186)," "...It is important to be safe while getting well... (p. 14)"" "Reflection about needing to be safe" 21(4.4) ""...It makes me realise I need to think about what I need to do until I am really back to normal... (p. 44)," "...I ignored it before like an idiot... (p.371)"" "Realised needs help/ will need to modify own behaviour" 164(34.7) Knowledge "Knowledge about falls and falls prevention" 52 (11) ""... This was good information to give to all patients... (p. 131)," "...helpful information... (p. 337)"" Informative 49 (10.4) ""...Useful, covered all points... (p. 187)," "...very helpful program... (p. 215)"" Useful/helpful 44(9.3) ""...Common sense, good to put theory into practice... (p. 584)," "...all good common sense... (p. 64)"" Common sense 19(4) ""...Found it very interesting...," "interesting: easy to follow... (p. 146)"" Interesting 136(28.8) Motivation "Motivation to engage in falls prevention strategies" 41(8.7) ""...Its darn good... (p. 626)," "...very helpful program... (p. 399)"" "Good programme- feeling positive after programme" 59 (12.5) ""...Enjoyed the DVD, very clear... (p. 565)," "...watched DVD together with roommate enjoyed it very much... (p. 404)"" "Enjoyment, excellent DVD" 36(7.6) ""...Good, will make me think twice before attempting to go on my own... (p. 516)," "...will be careful and get help... (p.306)"" "Motivated to change behaviour/empowering" 35(7.4) Confidence "Confidence to engage in falls prevention strategies" 24(5.1) ""It encouraged you to prevent falls... (p. 425)," "helps make me feel better about needing help... (p.96)"" Encouraging/reassuring 11 (2.3) ""...This will really help me feel confident... (p. 134)," "...it makes me more confident to speak to the physio about what I can and can't do... (p. 102)"" Gives confidence 46(9.7) "Modifying factors" "Modifying factors that facilitate taking action" 33(7) "" ...I care for my husband (so) all this information is really obvious and I realise it applies to me as well... (p. 111)"" "Personal/social circumstances" 13(2.7) ""...Reminded me of previous learning... have been to falls clinic before... (p. 418)"" Prior learning

| Frequency, $\mathrm{N}=473$ (100%) | HBM codes | Participants' survey responses | Subcategory | Generic category | | :---: | :---: | :---: | :---: | :---: | | 92 (19.4) | Awareness | | | Perceived susceptibility of risk of falls and injury | | $40(8.5)$ | | "...Made me more aware of falls risk... (p. 239)," "...opened my eyes to the risk of falls... (p.550)" | Increased awareness of falls risk | | | 31 (6.5) | | "...Puts it at the front of your mind... (p. 186)," "...It is important to be safe while getting well... (p. 14)" | Reflection about needing to be safe | | | $21(4.4)$ | | "...It makes me realise I need to think about what I need to do until I am really back to normal... (p. 44)," "...I ignored it before like an idiot... (p.371)" | Realised needs help/ will need to modify own behaviour | | | $164(34.7)$ | Knowledge | | | Knowledge about falls and falls prevention | | 52 (11) | | "... This was good information to give to all patients... (p. 131)," "...helpful information... (p. 337)" | Informative | | | 49 (10.4) | | "...Useful, covered all points... (p. 187)," "...very helpful program... (p. 215)" | Useful/helpful | | | $44(9.3)$ | | "...Common sense, good to put theory into practice... (p. 584)," "...all good common sense... (p. 64)" | Common sense | | | $19(4)$ | | "...Found it very interesting...," "interesting: easy to follow... (p. 146)" | Interesting | | | $136(28.8)$ | Motivation | | | Motivation to engage in falls prevention strategies | | $41(8.7)$ | | "...Its darn good... (p. 626)," "...very helpful program... (p. 399)" | Good programme- feeling positive after programme | | | 59 (12.5) | | "...Enjoyed the DVD, very clear... (p. 565)," "...watched DVD together with roommate enjoyed it very much... (p. 404)" | Enjoyment, excellent DVD | | | $36(7.6)$ | | "...Good, will make me think twice before attempting to go on my own... (p. 516)," "...will be careful and get help... (p.306)" | Motivated to change behaviour/empowering | | | $35(7.4)$ | Confidence | | | Confidence to engage in falls prevention strategies | | $24(5.1)$ | | "It encouraged you to prevent falls... (p. 425)," "helps make me feel better about needing help... (p.96)" | Encouraging/reassuring | | | 11 (2.3) | | "...This will really help me feel confident... (p. 134)," "...it makes me more confident to speak to the physio about what I can and can't do... (p. 102)" | Gives confidence | | | $46(9.7)$ | Modifying factors | | | Modifying factors that facilitate taking action | | $33(7)$ | | " ...I care for my husband (so) all this information is really obvious and I realise it applies to me as well... (p. 111)" | Personal/social circumstances | | | $13(2.7)$ | | "...Reminded me of previous learning... have been to falls clinic before... (p. 418)" | Prior learning | |

Figure 2 Participants’ responses to receiving the falls prevention education mapped against the framework of the HBM. HBM, health belief model.
图 2 根据 HBM 框架绘制了参与者对接受跌倒预防教育的反应。 HBM，健康信念模型。

Table 3 Participants’ identified barriers to engaging in their planned falls prevention strategies
表 3 参与者确定的参与计划的跌倒预防策略的障碍

频率，N=319 (100%)

Frequency,

N=319 (100%)

Participants' survey responses
参与者的调查回应

Subcategory 子类别

通用类别

Generic

DISCUSSION 讨论

This large cohort of older hospital patients on rehabilitation wards who received the Safe Recovery education programme consistently reported that the education effectively increased their knowledge and awareness about falls and falls prevention and that they developed confidence and motivation to engage in individualised falls prevention strategies. These results are supported by a previous study, which found that providing patients on rehabilitation wards with falls prevention education using the multimedia component of this programme raised knowledge, confidence and motivation to engage in falls prevention strategies.

^{18}

However, the education programme in this trial also assisted participants to develop personalised strategies to reduce their falls risk on the ward and resulted in a significant reduction in falls.

^{22}

Participants’ responses to receiving the education contrast with previous studies, which have found that older patients on either medical, rehabilitation, acute or subacute wards have low levels of awareness, knowledge and motivation to engage in falls prevention behaviours in hospital.

^{15} 2324

康复病房接受安全康复教育计划的一大群老年医院患者一致表示，教育有效提高了他们对跌倒和跌倒预防的知识和意识，并培养了他们采取个性化跌倒预防策略的信心和动力。这些结果得到了之前的一项研究的支持，该研究发现，使用该计划的多媒体部分为康复病房的患者提供跌倒预防教育，提高了参与跌倒预防策略的知识、信心和动力。

^{18}

然而，该试验中的教育计划还帮助参与者制定个性化策略，以降低他们在病房的跌倒风险，并导致跌倒次数显着减少。

^{22}

参与者对接受教育的反应与之前的研究形成鲜明对比，之前的研究发现，内科、康复、急性或亚急性病房的老年患者对在医院进行跌倒预防行为的意识、知识和动机水平较低。

^{15} 2324

The findings of the present study are important as they explain how education resulted in a significant reduction in falls and injurious falls rates among older
本研究的结果很重要，因为它们解释了教育如何显着减少老年人的跌倒和伤害性跌倒发生率

Figure 3 Participants’ identified barriers to engaging in planned falls prevention strategies. Adapted framework from Haines et al.

^{15}

图 3 参与者确定的参与计划的跌倒预防策略的障碍。改编自 Haines 等人的框架。

^{15}

patients when implemented in addition to usual care across eight hospital rehabilitation wards.

^{22}

The education programme was perceived by older participants as being ‘enjoyable’ and ‘very interesting’, in contrast to previous large community studies which have found that older people do not find falls information appealing or personally relevant and are not interested in finding out about how to reduce falls risk.

^{29 - 31}

Previous qualitative studies have also found that older patients can find falls prevention information confusing and can be passive about seeking out such education.

^{23}^{24}

However, when asked, older people have stated that they would like clear information and explanation about the benefits of engaging in falls prevention strategies.

^{32}

Participants’ positive responses to the programme were supported by earlier findings from educators of the programme.

^{21}

The educators suggested that the adult learning principles, which informed the education design, led to programme success. Allowing adults to be self-directive in their learning, acknowledging the experience the adult learner brings to the learning and ensuring content is personally relevant enhance engagement and motivation for learning.

^{19}

The educators felt that effectively engaging with the patient on this level was critical in facilitating development of patient motivation to participate in the programme.

^{21}

In the context of falls prevention education, this appeared helpful to overcome previous known barriers, namely that older people see little personal relevance and are reluctant to engage in discussion around falls and their prevention.

^{23} 3031

除了对八个医院康复病房进行常规护理外，还对患者进行了治疗。

^{22}

老年参与者认为该教育计划“令人愉快”和“非常有趣”，这与之前的大型社区研究形成鲜明对比，这些研究发现老年人并不认为跌倒信息有吸引力或与个人相关，并且对了解如何了解跌倒信息不感兴趣。以减少跌倒风险。

^{29 - 31}

先前的定性研究还发现，老年患者可能会发现预防跌倒的信息令人困惑，并且可能会被动地寻求此类教育。

^{23}^{24}

然而，当被问及时，老年人表示，他们希望获得关于采取跌倒预防策略的好处的明确信息和解释。

^{32}

参与者对该计划的积极反应得到了该计划教育工作者早期调查结果的支持。

^{21}

教育工作者认为，成人学习原则为教育设计提供了信息，从而导致了项目的成功。允许成人在学习中进行自我指导，承认成人学习者为学习带来的经验，并确保内容与个人相关，从而增强学习的参与度和动力。

^{19}

教育工作者认为，在这个层面上与患者有效互动对于促进患者参与该计划的积极性至关重要。

^{21}

在跌倒预防教育的背景下，这似乎有助于克服以前已知的障碍，即老年人很少看到个人相关性，并且不愿意参与有关跌倒及其预防的讨论。

^{23} 3031

Participants’ reported barriers to engaging in falls prevention strategies on rehabilitation wards were concordant with a previous conceptual framework that identified why older hospital patients might voluntarily engage in risk-taking behaviours that could lead to falls.

^{15}

Findings from the present study were from a much larger cohort and included a broad population of older hospital patients, providing further evidence in support of that framework. Participants’ thoughts and feelings were found to be the most important element that contributed to risk-taking behaviour. These findings highlight the importance of ongoing discussion and negotiation with older patients, as part of providing individually tailored strategies. This approach facilitates older patients to undertake rehabilitation in a safe manner while on the ward. Other qualitative work has also found that ongoing communication about falls risk and strategies to patients and families is important in enhancing falls prevention on hospital wards.

^{33}

Concepts of health behaviour change explain that patients require social opportunity (both physical, such as having access to a walking frame, and psychological, such as positive reinforcement by staff) to engage in falls prevention activities.

^{34}

Participants’ feedback was consistent with feedback from the educators who provided participants with the education programme. These educators reported that participants’ beliefs and attitudes were key influences in either facilitating or forming a barrier to engagement in falls prevention strategies.

^{21}

A few participants responded less positively, feeling that they already knew what to do or could maintain their independence. It was not surprising that patients also reported that feeling anxious, ill or tired made it difficult to remember and concentrate on engaging in safe mobility. Older patients may need more consistent affirmation and support from staff to engage in safe strategies when undertaking mobility tasks in hospital, which has also been suggested by other researchers who have examined the provision of falls education for older patients on acute hospital wards.

^{24}

This may be particularly true of people who are usually independent and not used to receiving assistance. Previous studies have found that toileting is a mobility task that is strongly associated with falls occurrence in hospitals.

^{10 - 12}

However, the findings in this study confirmed other qualitative findings that suggest that even when undertaking the task of toileting, patients’ perceptions about bothering staff or staff being too busy to help, rather than the task of toileting alone, contribute to toileting being identified as an activity that can heighten the risk of falls.

^{24}

参与者报告的在康复病房采取跌倒预防策略的障碍与之前的概念框架一致，该框架确定了为什么老年医院患者可能会自愿从事可能导致跌倒的冒险行为。

^{15}

本研究的结果来自更大的队列，包括大量老年医院患者，为支持该框架提供了进一步的证据。研究发现，参与者的想法和感受是促成冒险行为的最重要因素。这些发现强调了与老年患者持续讨论和谈判的重要性，作为提供个性化定制策略的一部分。这种方法有助于老年患者在病房期间以安全的方式进行康复。其他定性研究还发现，与患者和家属持续沟通跌倒风险和策略对于加强医院病房的跌倒预防非常重要。

^{33}

健康行为改变的概念解释说，患者需要社会机会（包括身体上的机会，例如使用助行架，和心理上的机会，例如工作人员的积极强化）来参与跌倒预防活动。

^{34}

参与者的反馈与为参与者提供教育计划的教育工作者的反馈一致。这些教育工作者报告说，参与者的信念和态度是促进或形成参与跌倒预防策略的障碍的关键影响因素。

^{21}

一些参与者的反应不太积极，认为他们已经知道该做什么或可以保持独立性。毫不奇怪，患者还报告说，感到焦虑、不适或疲倦使人难以记住并集中精力进行安全活动。老年患者在医院执行行动任务时可能需要工作人员更加一致的肯定和支持，以采取安全策略，其他研究人员也研究过为急诊病房老年患者提供跌倒教育，也提出了这一点。

^{24}

对于通常独立且不习惯接受援助的人来说尤其如此。先前的研究发现，如厕是一项移动任务，与医院跌倒发生密切相关。

^{10 - 12}

然而，这项研究的结果证实了其他定性发现，即即使在承担如厕任务时，患者对打扰工作人员或工作人员太忙而无法提供帮助的看法，而不是单独的如厕任务，也有助于将如厕视为可能增加跌倒风险的活动。

^{24}

This survey was limited by the nature of its administration. It was conducted among older hospital patients who were admitted to rehabilitation wards, and the focus was on providing patients with the programme and integrating the programme into patients’ daily rehabilitation. Participants were invited to make a response if they desired to and the educator did not follow-up these responses with probing or discussion. Some participants did not choose to provide a response, which could have been due to fatigue, reluctance to answer survey questions or time limitation for openended questions if they needed to engage in other ward tasks. A strength of this study was that the feedback was obtained from a large cohort of patients with a broad range of diagnoses who were part of a cluster trial across eight hospital sites and hence were not a highly selective sample. Therefore, the sample and study findings are likely to be representative and generalisable to older rehabilitation patients who have appropriate levels of cognition to receive individualised patient education. This education was delivered as part of a cluster RCT, and in our original trial, the education was provided to

\sim 50 %

of the rehabilitation patients throughout the intervention wards, with the remaining patients screened as having impaired cognition.

^{22}

Staff were trained to support the programme.

^{22}

The study setting was also a usual ward environment, not a hypothetical scenario. Participants had first-hand experience of trying to engage in falls prevention strategies in a normal rehabilitation ward environment, meaning that their perceptions of barriers to engaging in fall prevention strategies were founded in their experiences of real-world ward operations and processes. A limitation of the study design was that the survey was administered by the falls prevention educators. This may have heightened moderator bias. Participants may have considered it to be
这项调查受到其管理性质的限制。该项目针对入住康复病房的老年患者进行，重点是为患者提供该计划并将该计划融入患者的日常康复中。如果参与者愿意，他们会被邀请做出回应，而教育者并没有通过探究或讨论来跟进这些回应。一些参与者没有选择提供答复，这可能是由于疲劳、不愿回答调查问题或开放式问题的时间限制（如果他们需要从事其他病房任务）。这项研究的优势在于，反馈是从一大群诊断范围广泛的患者中获得的，这些患者是八个医院地点的集群试验的一部分，因此不是一个高度选择性的样本。因此，样本和研究结果可能对具有适当认知水平以接受个体化患者教育的老年康复患者具有代表性和普遍性。这种教育是作为集群随机对照试验的一部分提供的，在我们最初的试验中，教育是提供给

\sim 50 %

整个干预病房的康复患者均被筛查，其余患者则被筛查为认知障碍。

^{22}

工作人员接受了支持该计划的培训。

^{22}

研究环境也是通常的病房环境，而不是假设的场景。参与者拥有在正常康复病房环境中尝试参与跌倒预防策略的第一手经验，这意味着他们对参与跌倒预防策略的障碍的看法是建立在他们现实世界病房操作和流程的经验基础上的。研究设计的一个局限性是该调查是由跌倒预防教育工作者进行的。这可能会加剧主持人的偏见。参与者可能认为这是
socially undesirable to provide overtly negative responses about their education experiences directly to the educators. On the other hand, this may have also prompted participants to provide accurate responses regarding their goal setting and barriers to engagement as they were highly likely to have discussed personal goals and barriers during the education intervention sessions. We were also unable to interview staff at that time to gain their perception about the participants’ understanding about ward falls prevention. This would assist to add trustworthiness to these findings. Another limitation of the study was that it was conducted solely among older patients who had received the Safe Recovery programme. Findings from this study may not be able to be generalised to other hospital education interventions, such as those provided for asthma or diabetes, as patients may need to engage in more complex strategies for these conditions and require ongoing staff instruction.
社会不希望直接向教育工作者提供有关其教育经历的明显负面反应。另一方面，这也可能促使参与者就他们的目标设定和参与障碍提供准确的回答，因为他们很可能在教育干预会议期间讨论了个人目标和障碍。我们当时也无法采访工作人员，了解他们对参与者对预防病房跌倒的理解的看法。这将有助于增加这些发现的可信度。该研究的另一个局限性是它仅在接受过安全康复计划的老年患者中进行。这项研究的结果可能无法推广到其他医院教育干预措施，例如针对哮喘或糖尿病的教育干预措施，因为患者可能需要针对这些情况采取更复杂的策略，并需要持续的工作人员指导。

CONCLUSION 结论

Older hospital patients admitted to rehabilitation wards with good levels of cognition, who were provided with individualised falls prevention education, reported that the education raised their awareness and knowledge about the risk of falls and falls prevention strategies. They also developed the confidence and motivation to engage in falls prevention by implementing individualised planned strategies. The main barrier they identified to engaging in such strategies was their own thoughts and feelings about their recovery, which could result in them engaging in risk-taking activity. Ongoing communication between patients and staff about the process of recovery is important in assisting older rehabilitation patients, who have adequate levels of cognition, to engage in falls prevention strategies while they are in hospital. Future research should continue to investigate how to provide effective falls prevention education in hospitals for other older patient populations.
认知水平良好的康复病房收治的老年住院患者接受了个性化的跌倒预防教育，他们表示，教育提高了他们对跌倒风险和跌倒预防策略的认识和了解。他们还通过实施个性化的计划策略，培养了参与跌倒预防的信心和动力。他们发现采用此类策略的主要障碍是他们自己对康复的想法和感受，这可能导致他们从事冒险活动。患者和工作人员之间关于康复过程的持续沟通对于帮助具有足够认知水平的老年康复患者在住院期间采取跌倒预防策略非常重要。未来的研究应继续调查如何在医院为其他老年患者群体提供有效的跌倒预防教育。

Author affiliations 作者隶属关系

^{1}

School of Physiotherapy and Exercise Science, Curtin University, Perth, Western Australia, Australia

^{1}

科廷大学物理治疗与运动科学学院，澳大利亚西澳大利亚州珀斯

^{2}

Institute for Health Research, The University of Notre Dame Australia, Fremantle, Western Australia, Australia

^{2}

澳大利亚圣母大学健康研究所，弗里曼特尔，西澳大利亚州，澳大利亚

^{3}

School of Physiotherapy, The University of Notre Dame Australia, Fremantle, Western Australia, Australia

^{3}

澳大利亚圣母大学物理治疗学院，弗里曼特尔，西澳大利亚州，澳大利亚

^{4}

Department of Physiotherapy, Monash University, Melbourne, Victoria, Australia

^{4}

澳大利亚维多利亚州墨尔本莫纳什大学物理治疗系

^{5}

Allied Health Research Unit, Monash Health, Melbourne, Victoria, Australia

^{5}

联合健康研究单位，莫纳什健康中心，墨尔本，维多利亚州，澳大利亚

^{6}

Department of Rehabilitation and Aged Care, Armadale Kelmscott Memorial Hospital, Perth, Western Australia, Australia

^{6}

阿马代尔凯尔斯科特纪念医院康复和老年护理部，珀斯，西澳大利亚州，澳大利亚

^{7}

Health Strategy and Networks, Strategic System, Policy & Planning, Department of Health, Government of Western Australia, Perth, Western Australia, Australia

^{7}

卫生战略和网络、战略系统、政策与规划，西澳大利亚州政府卫生部，珀斯，西澳大利亚州，澳大利亚

^{8}

WA Centre for Health and Ageing, Royal Perth Hospital Unit, School of Medicine & Pharmacology and Centre for Medical Research, University of Western Australia, Perth, Western Australia, Australia

^{8}

西澳健康与老龄化中心、皇家珀斯医院科室、西澳大利亚大学医学与药理学学院和医学研究中心，珀斯，西澳大利亚州，澳大利亚

^{9}

Department of Rehabilitation and Aged Care, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia

^{9}

查尔斯·盖尔德纳爵士医院康复和老年护理部，珀斯，西澳大利亚州，澳大利亚

^{10}

Centre for Functioning and Health Research, Metro South Health, Brisbane, Queensland, Australia

^{11}

Institute of Health and Biomedical Innovation and School of Public Health & Social Work, Queensland University of Technology, Brisbane, Queensland, Australia

^{10}

澳大利亚昆士兰州布里斯班 Metro South Health 功能与健康研究中心

^{11}

昆士兰科技大学健康与生物医学创新研究所和公共卫生与社会工作学院，澳大利亚昆士兰州布里斯班

Acknowledgements SMM and TPH are supported by National Health and Medical Research Council (of Australia) Career Development awards.
致谢 SMM 和 TPH 得到（澳大利亚）国家健康和医学研究委员会职业发展奖的支持。

Contributors A-MH contributed to study conception, design, intervention training, data collection and analyses, principal manuscript drafting and editing. SMM contributed to study conception, design, data management and analyses, manuscript drafting, appraisal and editing. JF-C contributed to study conception, design, data collection and analyses, manuscript drafting, appraisal and editing. NW, CE-B, LF and KI contributed to study conception, design, and site management and provided advice on data collection, management and analysis. TPH contributed to study conception and design and intervention training. All authors contributed to manuscript appraisal, revision and editing and read and approved the final manuscript.
贡献者 A-MH 为研究构思、设计、干预培训、数据收集和分析、主要手稿起草和编辑做出了贡献。 SMM 为研究构思、设计、数据管理和分析、稿件起草、评估和编辑做出了贡献。 JF-C 为研究构思、设计、数据收集和分析、手稿起草、评估和编辑做出了贡献。 NW、CE-B、LF 和 KI 为研究构思、设计和现场管理做出了贡献，并就数据收集、管理和分析提供了建议。 TPH 为研究构思、设计以及干预培训做出了贡献。所有作者都参与了稿件评审、修改和编辑，并阅读并批准了最终稿件。

Funding This work was supported by the Western Australian State Health Research Advisory Council and the Department of Health, Western Australia as part of the Research Translation Projects programme. This programme was established to encourage research and translation of outcomes into healthcare policy and practice. The key aim of the projects is to demonstrate improved cost-effectiveness and/or efficiencies to WA Health while maintaining or improving patient outcomes.
资助作为研究翻译项目计划的一部分，这项工作得到了西澳大利亚州卫生研究咨询委员会和西澳大利亚卫生部的支持。该计划的建立是为了鼓励研究并将结果转化为医疗保健政策和实践。这些项目的主要目标是展示西澳卫生局的成本效益和/或效率的提高，同时维持或改善患者的治疗效果。

Competing interests None declared.
竞争利益未声明。
Ethics approval Ethical approval was obtained from The University of Notre Dame Australia HREC and Sir Charles Gairdner Hospital (North Metropolitan Health Service Department Health WA) HREC.
道德批准道德批准获得了澳大利亚圣母大学 HREC 和 Charles Gairdner 爵士医院（西澳北大都会卫生服务部卫生局）HREC。

Provenance and peer review Not commissioned; externally peer reviewed.
出处和同行评审未委托；外部同行评审。
Data sharing statement No additional data are available.
数据共享声明无其他可用数据。
Open Access This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work noncommercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http:// creativecommons.org/licenses/by-nc/4.0/
开放获取这是根据知识共享署名非商业 (CC BY-NC 4.0) 许可证分发的开放获取文章，该许可证允许其他人以非商业方式分发、重新混合、改编、在此作品的基础上进行构建，并在不同的平台上许可其衍生作品。条款，前提是正确引用原始作品并且使用是非商业性的。请参阅：http: //creativecommons.org/licenses/by-nc/4.0/

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BMJ Open 'My independent streak may get in the way': how older adults respond to falls prevention education in hospital BMJ Open“我的独立倾向可能会妨碍”：老年人如何应对医院的跌倒预防教育