Specific item patterns in comparison to generalized sum score-the Care Dependency Scale (CDS) as a screening tool for specific care problems.

AIMS: The aim of this study is to identify items of the Care Dependency Scale (CDS) with overriding importance for the specific nursing care problems of pressure ulcers, falls, and malnutrition. METHOD: Secondary data analysis of 5 multicentre consecutive annual cross-sectional surveys from 2008 to 2012. For the study, data were analysed from 19 787 individuals in 262 long-term care facilities throughout Germany. Based on a standardized study protocol and international definitions, data regarding care dependency and care problems were gathered by direct examination. To identify the most relevant items of the CDS regarding pressure ulcers, falls, and malnutrition, classification trees (Classification and Regression Trees) were calculated. The validity of the identified items was then confirmed by applying "area under the receiver operating characteristic curve (AUC)" statistics. RESULTS: The Classification and Regression Tree analysis showed a total of 6 nodes for pressure ulcer prevalence on 2 levels. Both levels provided the CDS item mobility as the most important predictor for the prevalence of pressure ulcers with a prevalence of 9.0% for these being completely dependent. The most important CDS item to determine malnutrition is completely dependent on eat and drink with a malnutrition prevalence of 25.2%. Of all CDS items that have been entered into the model, the item mobility showed the strongest association with falls. For pressure ulcers, the CDS items mobility (0.72) and body posture (0.71) provided a higher AUC than the total CDS sum score. Furthermore, for malnutrition, we measured an AUC of 0.63 for item eat and drink while the total CDS provided an AUC of 0.62. CONCLUSIONS: The results of our study suggest that the CDS may be a useful tool for screening patients regarding the risk of pressure ulcers and/or malnutrition. According to our study, the CDS can be used as an assessment for many different care problems.

Validation and clinical impact of paediatric pressure ulcer risk assessment scales: A systematic review.

BACKGROUND: Pressure ulcer risk assessment using an age-appropriate, valid and reliable tool is recommended for clinical paediatric practice. OBJECTIVES: (1) What PU risk scales for children currently exist? (2) What is the diagnostic accuracy of their scores? (3) Are the scores reliable and what is the degree of agreement? (4) What is the clinical impact of risk scale scores in paediatric practice? DESIGN: Systematic review. DATA SOURCES: MEDLINE (1950 to December 2010), EMBASE (1989 to December 2010), CINAHL (1982 to December 2010), reference lists. REVIEW METHODS: Two reviewers independently screened databases, selected and evaluated articles and studies. Diagnostic accuracy, reliability/agreement, and experimental studies investigating the performance and clinical impact of PU risk scale scores in the paediatric population (0-18 years) were included. PU development was used as reference standard for diagnostic accuracy studies. Methodological quality of the validity and reliability studies was assessed based on the QUADAS and QAREL checklists. RESULTS: The search yielded 1141 hints. Finally, 15 publications describing or applying 12 paediatric pressure ulcer risk scales were included. Three of these scales (Neonatal Skin Risk Assessment Scale for Predicting Skin Breakdown, Braden Q Scale, Burn Pressure Skin Risk Assessment Scale) were investigated in prospective validation studies. Empirical evidence about interrater reliability and agreement is available for four instruments (Neonatal Skin Risk Assessment Scale for Predicting Skin Breakdown, Starkid Skin Scale, Glamorgan Scale, Burn Pressure Ulcer Risk Assessment Scale). No studies were identified investigating the clinical impact. CONCLUSIONS: Sound empirical evidence about the performance of paediatric pressure ulcer risk assessment scales is lacking. Based on the few results of this review no instrument can be regarded as superior to the others. Whether the application of pressure ulcer risk assessment scales reduces the pressure ulcer incidence in paediatric practice is unknown. Maybe clinical judgement is more efficient in evaluating pressure ulcer risk than the application of risk scale scores.

Why older persons seek nursing care: towards a conceptual model.

Despite similar health problems, older persons show different care seeking behaviours for a variety of reasons. The aim of this study was to identify motives underlying the attitudes of older persons to seek nursing care and to develop a theoretical rationale which allows viewing their mutual interaction. Theory development according to Walker and Avant was used as a method to derive a model from the reviewed literature. Six categories were identified that may influence seeking of nursing care: perceived threat, disposition, external options & barriers, current coping abilities, influence of significant others, and outcome value. Findings do not allow determination of factors that may predict care seeking attitude but provide a loosely structured conceptual model for culture specific investigations. Qualitative studies guided by the model should be conducted in order to develop testable theories of care seeking for different cultures and settings.

Psychosocial problems and needs of posttreatment patients with breast cancer and their relatives.

PURPOSE: The study assessed and compared the psychosocial needs of patients with breast cancer and of their relatives, the patients' and relatives' burden of illness, anxiety, depression and distress and assessed the patients' cancer treatment-related symptoms and identified relevant factors influencing patients' and relatives' needs. METHOD: Seventy-two patients (n=72) participated with a relative in a cross-sectional mail-survey, 1-22 months after cancer treatment. RESULTS: The patients reported needing help with psychological and sexual issues. They suffered from treatment-related symptoms. More treatment-related symptoms and depression were related to the patients' needs for supportive care. Their relatives' needs primarily concerned access to information and communication with health care professionals. Relatives had higher levels of anxiety (25.0% vs. 22.2%), depression (12.5% vs. 8.3%) and distress (40% vs. 34%) than patients. Higher levels of depression, younger age and having a disease themselves were associated with relatives' need for help. CONCLUSION: Patients' and relatives' substantial needs and psychological problems require professional support even after completion of the patients' treatment. Continued assessment of the patients' and their relatives' needs and of the patients' symptoms provide the basis for purposeful counselling and education. Rehabilitation programs for patients and their relatives should be developed and implemented in clinical practice.

Diagnostic accuracy of two pressure ulcer risk scales and a generic nursing assessment tool. A psychometric comparison.

AIM: Comparison of the diagnostic accuracy of two pressure ulcer risk assessment scales and one generic nursing assessment tool. BACKGROUND: Guidelines for pressure ulcer prevention recommend an initial risk screening of all patients, followed by appropriate nursing interventions. Additionally, personal and financial resources have to be allocated carefully to avoid excessive or too little treatment. Risk assessments should be accurate and applicable, and some studies showed that generic nursing tools also provide specific information for nursing diagnoses, like risk for pressure ulcer. DESIGN: Cross sectional observational study. METHODS: A total of 1053 adult patients of a university hospital in Germany were investigated. For each patient, the Braden Scale, the Waterlow Scale and the Care Dependency Scale were completed. A skin inspection was conducted by trained nurses. Correlations between the three scales and the mean values of each pressure ulcer risk assessment scales for each Care Dependency Scale value were calculated. To determine the association between susceptibility to pressure ulcer and observed pressure ulcer, the area under the curve was calculated. RESULTS: There was a higher correlation between the Braden Scale and the Care Dependency Scale (r = 0.82) than between the two pressure ulcer risk assessment scales (-0.65). The highest area under the curve was reached by the Braden Scale (0.86), followed by the Care Dependency Scale (0.83) and the Waterlow Scale (0.81). Only the Braden Scale (cut-off 18) and the Care Dependency Scale (cut-off 65) reached the psychometric requirements of at least 70% sensitivity and 70% specificity. CONCLUSIONS: The Care Dependency Scale could be used for both a general nursing assessment and as a screening tool for risk for pressure ulcers. The Braden Scale showed the highest association with the occurrence of pressure ulcer. RELEVANCE TO CLINICAL PRACTICE: The Care Dependency Scale is a useful screening tool to identify patients at risk for pressure ulcers. Nursing assessment activities might be reduced by using a generic nursing assessment tool also for specific risk screening.

Socio-demographic factors related to functional limitations and care dependency among older Egyptians.

AIM: This paper is a report of a study determining the relationship of socio-demographic factors to functional limitations and care dependency among older care recipients and non-care recipients in Egypt. BACKGROUND: The population is ageing in Egypt and age-related functional limitations are increasing. Age and gender influence this phenomenon, but its relationship to socio-economic status has not yet been demonstrated for Egypt. Functional limitations are an antecedent to care dependency, which also may be associated with these socio-demographic factors. METHOD: A cross-sectional study with a two-group comparative design was conducted in Greater Cairo. The sample was composed of 267 non-care recipients and 344 care recipients. Path analysis was used to determine the relationship between variables. Age, gender and acceptance of care were covariates in the multiple regressions. Analyses were conducted separately for care recipients and non-care recipients. RESULTS: Among non-care recipients, lower socio-economic status was related to more functional limitations and higher care dependency. This relationship was not found among care recipients. CONCLUSION: Older persons from low income groups are more likely to become care dependent but are less able to pay for required care. Currently, untrained volunteer groups of religious organizations try to support these older people in the poorer strata of Egyptian society. Training in the basics of care might help to make their work more effective.

Pressure ulcer risk assessment in critical care: interrater reliability and validity studies of the Braden and Waterlow scales and subjective ratings in two intensive care units.

BACKGROUND: The application of standardized pressure ulcer risk assessment scales is recommended in clinical practice. OBJECTIVES: The aims of this study were to compare the interrater reliabilities of the Braden and Waterlow scores and subjective pressure ulcer risk assessment and to determine the construct validity of these three assessment approaches. DESIGN: Observational. SETTINGS: Two intensive care units of a large University Hospital in Germany. PARTICIPANTS: 21 and 24 patients were assessed by 53 nurses. Patients' mean age was 69.7 (SD 8.3) and 67.2 (SD 11.3). METHODS: Two interrater reliability studies were conducted. Samples of patients were assessed independently by a sample of three nurses. A 10-cm visual analogue scale was applied to measure subjective pressure ulcer risk rating. Intraclass correlation coefficients (ICC) and standard errors of measurement (SEM) were used to determine interrater reliability and agreement of the item and sum scores. Pearson product moment correlation coefficients (r) were used to indicate the degree and direction of the relationships between the measures. RESULTS: The interrater reliability for the subjective pressure ulcer risk assessment was ICC(1,1)=0.51 (95% CI 0.26-0.74) and 0.71 (95% CI 0.53-0.85). Interrater reliability of Braden scale sum scores was ICC(1,1)=0.72 (95% CI 0.52-0.87) and 0.84 (95% CI 0.72-0.92) and for Waterlow scale sum scores ICC(1,1)=0.36 (95% CI 0.09-0.63) and 0.51 (95% CI 0.27-0.72). The absolute degree of correlation between the measures ranged from 0.51 to 0.77. CONCLUSIONS: Interrater reliability coefficients indicate a high degree of measurement error inherent in the scores. Compared to subjective risk assessment and the Waterlow scale scores the Braden scale performed best. However, measurement error is too high to draw valid inferences for individuals. Less than 26-59% of variances in scores of one scale were determined by scores of another scale indicating that all three instruments only partly measured the same construct. The use of the Braden-, Waterlow- and Visual Analogue scales for measuring pressure ulcer risk of intensive care unit patients is not recommended.

Quality-of-life assessment in a palliative care setting in Germany: an outcome evaluation.

Quality-of-life (QoL) assessment is crucial for the evaluation of a palliative care outcome. This article investigates the applicability of the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30) on a German sample of terminally ill cancer patients receiving palliative care in different settings. Patients were randomly selected in 10 palliative homecare services and one palliative care unit in a general hospital and 'evaluated' among the consecutively 'registered' patients. The random sample of patients (n-121) was representative of the general patient population cared for by the palliative care services in Germany. The EORTC QLQ-C30 was administered to the terminally ill cancer patients on their first day in hospital or upon their first contact with the specialized palliative homecare team. The clinical variable assessed was the Karnofsky performance status. The questionnaire was well accepted in the present patient population. In addition, the questionnaire was found to be useful in detecting the effectiveness of palliative treatment over a period of time. This study shows that QoL measures can be used to assess the outcome in palliative care.

An interrater reliability study of the assessment of pressure ulcer risk using the Braden scale and the classification of pressure ulcers in a home care setting.

BACKGROUND: Measurement error can seriously affect the validity of pressure ulcer risk assessment and of pressure ulcer classification. OBJECTIVES: Determination of interrater reliability and agreement of pressure ulcer risk and pressure ulcers using the Braden scale and the EPUAP system. DESIGN AND SETTING: Duplicate assessments by trained nurses during two nationwide pressure ulcer prevalence surveys in the years 2007 and 2008 in The Netherlands in the home care setting. PARTICIPANTS: Home care clients which participated in 2007 (n=352) and 2008 (n=339) in the pressure ulcer prevalence surveys. METHODS: The Braden scale was used to assess pressure ulcer risk. Skin examination was conducted to detect pressure related tissue damages and to classify them according to the EPUAP. RESULTS: In 2007 and 2008, Intraclass Correlation Coefficients for Braden scale sum scores were 0.90 (95% CI: 0.88-0.92) and 0.88 (95% CI: 0.85-0.91) respectively, and corresponding Standard Errors of Measurement were 1.00 and 0.98. 95% limits of agreement were -2.8 to 2.8 and -2.7 to 2.7 respectively. The items "moisture", "sensory perception" and "nutrition" contained largest amounts of measurement error. Proportions of agreement for the classification of pressure ulcers were 96% and interrater reliability was 0.81 and 0.79. Most disagreements were observed for the classification of grade 1 pressure ulcers. CONCLUSIONS: The standardized study procedure applied in the annual nationwide pressure ulcer prevalence surveys leads to reliable and reproducible results regarding pressure ulcer risk and pressure ulcer prevalence in the home care setting. Researchers and practitioners should be careful when drawing inferences from single pressure ulcer risk factors included in the Braden scale. Descriptions of the items "moisture", "sensory perception" and "nutrition" should be made more clearly and unambiguous.

A review of psychosocial needs of breast-cancer patients and their relatives.

AIM: To identify the psychosocial needs of breast-cancer patients and their relatives along with factors affecting these needs and to develop a tentative model to guide further research and need assessments in clinical practice. BACKGROUND: Women experiencing breast cancer must deal with the diagnosis of a life-threatening illness. Treatment and the recovery process can be demanding for patients and their relatives. Need assessment may help clinicians focus on providing appropriate help. DESIGN: Literature review. METHOD: Undertaken using electronic databases and specific research terms; 20 articles were identified and analysed. RESULTS: The needs identified by patients involve (1) treatment-related physical and social impairment like fatigue, menopausal symptoms and a changed body image and (2) emotional distress like fear of recurrence, anxiety and depression. Partners need help to protect themselves and the patient from different threats. Women need information to maintain control and manage their illness. Partners want information concerning the patient's condition and both of them about the prognosis and perspectives. There is a lack of knowledge of relatives' needs. Mutual familial support, women's and partners' health and emotional distress may affect the interaction between the patients and their partners. CONCLUSIONS: A tentative family-based model to guide further research and clinical support is proposed. Further research is needed to determine precisely which psychosocial factors may influence fulfilment of the patients' and relatives' needs. RELEVANCE TO CLINICAL PRACTICE: The proposed model may provide a framework for healthcare professionals to evaluate the patients' and relatives' met and unmet needs and the real demand for help, to guide care planning, counselling and education.

Structured risk assessment and violence in acute psychiatric wards: randomised controlled trial.

BACKGROUND: There is a lack of research on the possible contribution of a structured risk assessment to the reduction of aggression in psychiatric in-patient care. AIMS: To assess whether such risk assessments decrease the incidence of violence and coercion. METHOD: A cluster randomised controlled trial was conducted with 14 acute psychiatric admission wards as the units of randomisation, including a preference arm. The intervention comprised a standardised risk assessment following admission with mandatory evaluation of prevention in high-risk patients. RESULTS: Incidence rates decreased substantially in the intervention wards, whereas little change occurred in the control wards. The adjusted risk ratios suggest a 41% reduction in severe aggressive incidents and a 27% decline in the use of coercive measures. The severity of aggressive incidents did not decrease. CONCLUSIONS: Structured risk assessment during the first days of treatment may contribute to reduced violence and coercion in acute psychiatric wards.

Pressure ulcer risk screening in hospitals and nursing homes with a general nursing assessment tool: evaluation of the care dependency scale.

RATIONALE: In view of an increasing necessity for systematic assessments, nursing practice would benefit from a simplification of assessment procedures. These assessments should be scientifically based. AIMS: To evaluate the possibility of assessing pressure ulcer risk as well as care dependency simultaneously with a standardized instrument for nursing homes and hospitals. METHODS: Care dependency was measured with the Care Dependency Scale (CDS). The quantitative analyses were accomplished with data from a cross-sectional study that was performed in 2005 in 39 German nursing homes and 37 hospitals with a total of more than 10,000 participants. The scale's construct validity was calculated with Pearson's r, and predictive validity was evaluated by computing sensitivity and specificity values and the area under the curve (AUC). Item-level analyses included calculations of odds ratios, relative risks and logistic regression analyses. RESULTS: Construct validity of the CDS was r = 0.79 (P < 0.01) in nursing homes and r = 0.89 (P < 0.01) in hospitals. AUC was 0.80 in hospitals and 0.65 in nursing homes. Analyses on item level identified 'mobility' as a key item in both settings and additional differing key items for nursing homes and hospitals. CONCLUSIONS: The CDS is a well-functioning tool for pressure ulcer risk detection in hospitals. For this purpose, the most appropriate cut-off point is 69 while special regard is given to the items 'continence', 'mobility' and 'hygiene'. In nursing homes the usefulness of the CDS for pressure ulcer risk detection is limited. Here, the most appropriate cut-off point is 41 and attention is given to the items 'mobility', 'getting (un)dressed', 'hygiene' and 'avoidance of danger'.

Care dependency of children in Egypt.

AIMS: This study aimed to modify the Care Dependency Scale so that it could be used for children, to apply its Arabic version to Egyptian children to test the reliability and validity of the modified scale and to compare the care dependency of disabled and non-disabled Egyptian children. BACKGROUND: A higher dependence of children in their daily tasks undoubtedly places a greater burden on their caregivers. To estimate the extent of the problem of care dependency, data from different countries and proper standard instruments are required. METHOD: The Care Dependency Scale was modified for children by Delphi technique. This study assessed the care dependency of non-disabled children compared with children with physical and mental disabilities using the modified version of the Care Dependency Scale for paediatrics. The total sample included 260 Egyptian school-age children (50.8% of whom were disabled and 49.2% were non-disabled). RESULTS: Reliability was examined in terms of internal consistency using Cronbach's alpha (0.91). Inter-rater reliability revealed moderate to very good Kappa statistics between 0.57-0.89. Content validity and criterion validity were evaluated. Differences regarding care dependency were found between disabled and non-disabled children. CONCLUSION: The psychometric properties of the Care Dependency Scale for paediatrics support its usefulness in measuring the care dependency of children in Egypt. This study provides an Arabic version of the Care Dependency Scale for paediatrics that is easy to administer and may be useful to measure the care dependency in various Arabic countries. RELEVANCE TO CLINICAL PRACTICE: The findings raise concerns regarding the extent to which disabled and also non-disabled school-age children are care dependent leading to an increased burden of care on nurses or on caregivers in general. The Care Dependency Scale for Paediatrics can help nurses conduct an appropriate assessment of children's care dependency so that any nursing care can be planned according to the children's needs.

The meaning of care dependency as shared by care givers and care recipients: a concept analysis.

AIM: This paper is a report of a concept analysis to identify a meaning of care dependency that can be shared by both care givers and care recipients. BACKGROUND: Care dependency can be perceived from the care recipient's and the care giver's perspective. To allow for comparisons, both sides should share the same understanding of the concept. The current research about care dependency has focused on external assessment by nurses and suffers from a tendency to use the concept with different meanings. As a consequence, research on dependency may capture different phenomena. METHOD: Walker and Avant's method for concept analysis served as the guideline for this study. The Medline, CINAHL and Cochrane databases were searched for the period 1996-2006 using the terms dependence, dependency, care dependence and care dependency. RESULTS: Care dependency can be defined as a subjective, secondary need for support in the domain of care to compensate a self-care deficit. Functional limitations are a necessary antecedent and unmet needs are a possible consequence of care dependency. The conceptual difference between care dependency, functional limitations and unmet needs may be meaningless for study participants. They may better understand these differences if they are asked about all three phenomena in the same investigation. CONCLUSION: Care givers and care recipients can agree on the suggested attributes of care dependency but may judge them in different ways. Self-assessed care dependency has the potential to challenge preconceptions of care givers about care dependency.

Pressure ulcer risk assessment immediately after cardiac surgery--does it make a difference? A comparison of three pressure ulcer risk assessment instruments within a cardiac surgery population.

The intensive care unit (ICU) population has a high risk of developing pressure ulcers. According to several national expert guidelines for pressure ulcer prevention, a risk assessment for every situation in which the patient's condition is changing should be performed using a standardized risk assessment instrument. The aims of this study were to (a) assess the number of patients who are 'at risk' for the development of pressure ulcer according to three commonly used risk assessment instruments in the intermediate period after cardiac surgery procedures, (b) assess which instrument best fits the situation of the ICU patients and c) decide if 'static' risk assessment with an instrument should be recommended. The modified Norton scale, the Braden scale and the 4-factor model were used in a convenience sample of 53 patients to assess the risk for development of pressure ulcer in the first 5 days (in ICU) after cardiac surgery procedures. The number of patients at risk were >60% by the 4-factor model, >70% by the modified Norton scale and >80% by the Braden scale. Sensitivity and specificity in all scales were not satisfactory. Forty-nine per cent (n= 26) of the patients developed a pressure ulcer in the operating room, 13% (n= 7) up to day 5 in the cardiac surgery ICU. Only 1.9% (n= 1) of the pressure ulcers were stage 2. The study concluded that the patients in the cardiac surgery ICU can be identified as at risk during the first 5 days after surgical procedure without continuously using a standardized risk assessment instrument in every changing condition. Individual risk assessment by a standardized risk assessment instrument is only recommended to enable initiation of preventive measures based on patient-specific risk factors.

Care dependency among school-aged children: literature review.

Many disabilities and chronic illnesses of children result in those children being dependent on their caregivers. The higher dependence of children in their daily tasks undoubtedly places a greater burden on their caregivers and on care-providers in the health-care system, especially nurses. The objectives were to gain an overview of the literature dealing with care dependency among children and the factors possibly influencing their dependency on care, and to obtain instruments for measuring children's care dependency. MEDLINE, CINAHL, and PsychINFO were searched for different publications from 1995 to 2005. The literature reveals four categories of factors associated with care dependency of the child. With respect to instruments, a variety of instruments were identified but most of them were restricted to children with specific health conditions. For this reason, the paper suggests the development of a new instrument for assessing children's care dependency that is applicable to healthy children.

Nursing students' experiences in managing patient aggression.

BACKGROUND: Nursing students are at high risk to become a victim of patient aggression. There is little evidence that training programmes developed for post-registered nurses or nurses in psychiatric or forensic settings can meet the needs of nursing students. To gain more insight into student nurses' educational outcomes in Germany the view of the target group was explored. METHODS: Twelve nursing students participated in semi-structured interviews. Data were evaluated by qualitative content analysis. RESULTS: Managing patient aggression is a general challenge for nursing students and is not confined to psychiatric settings. Specific problems of beginners became evident. Additionally, general issues were addressed on control of causes of aggression, interpretation aggressive situations, dealing with the aggressive patient, coping with stress, and organizational issues. CONCLUSION: Nursing students need preparation and training in handling patient aggression. They should acquire knowledge about aggression, awareness of contributing problems, self-confidence in dealing with aggressive patients, assertiveness and empathy in communication and the ability to cope in an appropriate manner. In addition the safety policy of hospital placements should be examined for appropriateness to support nursing students.

Falls in German in-patients and residents over 65 years of age.

AIMS AND OBJECTIVES: The aim of the present study was to describe the first fall rates in hospitals and nursing homes throughout Germany. Relationships between age, gender, care dependency, medical disciplines, bed confinement and falls were investigated. BACKGROUND: Little is known about fall rates in German hospitals and nursing homes. METHOD: Prevalence studies were conducted in the year 2002 and 2004. Forty hospitals and 15 nursing homes took part in 2002 (3923 patients and 1252 residents older than 65 years) and in 2004 there was a total of 39 hospitals and 29 nursing homes (4451 patients and 2374 residents older than 65 years). Staff nurses used a standardized instrument to collect data about falls in the last two weeks in their institutions and also about other patient problems. Descriptive and inferential statistics were used as well as logistic regression. RESULTS: The first fall rate in 2002 (2004) in the hospitals was 4.7 (4.2) and in the nursing homes 4.5 (5.1) per 1000 patient/resident days. Most of the hospital patients fell on geriatric wards. The high care dependent patients fell more often than the low care dependent patients. In 2002, mobile nursing home residents were at a higher risk of falling than residents confined to bed, but those results could not be confirmed in 2004. Conclusions. Falls of patients over 65 years of age are as much of a problem in German hospitals as they are in German nursing homes. RELEVANCE TO CLINICAL PRACTICE: Fall preventive methods should be implemented both in nursing homes and hospitals. Care dependency is a stable risk factor for falls in hospital patients.