Environmental interventions for preventing falls in older people living in the community.

BACKGROUND: Falls and fall-related injuries are common. A third of community-dwelling people aged over 65 years fall each year. Falls can have serious consequences including restricting activity or institutionalisation. This review updates the previous evidence for environmental interventions in fall prevention. OBJECTIVES: To assess the effects (benefits and harms) of environmental interventions (such as fall-hazard reduction, assistive technology, home modifications, and education) for preventing falls in older people living in the community. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, other databases, trial registers, and reference lists of systematic reviews to January 2021. We contacted researchers in the field to identify additional studies. SELECTION CRITERIA: We included randomised controlled trials evaluating the effects of environmental interventions (such as reduction of fall hazards in the home, assistive devices) on falls in community-residing people aged 60 years and over.   DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. Our primary outcome was rate of falls. MAIN RESULTS: We included 22 studies from 10 countries involving 8463 community-residing older people. Participants were on average 78 years old, and 65% were women. For fall outcomes, five studies had high risk of bias and most studies had unclear risk of bias for one or more risk of bias domains. For other outcomes (e.g. fractures), most studies were at high risk of detection bias. We downgraded the certainty of the evidence for high risk of bias, imprecision, and/or inconsistency.  Home fall-hazard reduction (14 studies, 5830 participants) These interventions aim to reduce falls by assessing fall hazards and making environmental safety adaptations (e.g. non-slip strips on steps) or behavioural strategies (e.g. avoiding clutter).  Home fall-hazard interventions probably reduce the overall rate of falls by 26% (rate ratio (RaR) 0.74, 95% confidence interval (CI) 0.61 to 0.91; 12 studies, 5293 participants; moderate-certainty evidence); based on a control group risk of 1319 falls per 1000 people a year, this is 343 (95% CI 118 to 514) fewer falls. However, these interventions were more effective in people who are selected for higher risk of falling, with a reduction of 38% (RaR 0.62, 95% CI 0.56 to 0.70; 9 studies, 1513 participants; 702 (95% CI 554 to 812) fewer falls based on a control risk of 1847 falls per 1000 people; high-certainty evidence). We found no evidence of a reduction in rate of falls when people were not selected for fall risk (RaR 1.05, 95% CI 0.96 to 1.16; 6 studies, 3780 participants; high-certainty evidence). Findings were similar for the number of people experiencing one or more falls. These interventions probably reduce the overall risk by 11% (risk ratio (RR) 0.89, 95% CI 0.82 to 0.97; 12 studies, 5253 participants; moderate-certainty evidence); based on a risk of 519 per 1000 people per year, this is 57 (95% CI 15 to 93) fewer fallers. However, for people at higher risk of falling, we found a 26% decrease in risk (RR 0.74, 95% CI 0.65 to 0.85; 9 studies, 1473 participants), but no decrease for unselected populations (RR 0.99, 95% CI 0.92 to 1.07; 6 studies, 3780 participants) (high-certainty evidence). These interventions probably make little or no important difference to health-related quality of life (HRQoL) (standardised mean difference 0.09, 95% CI -0.10 to 0.27; 5 studies, 1848 participants; moderate-certainty evidence). They may make little or no difference to the risk of fall-related fractures (RR 1.00, 95% 0.98 to 1.02; 2 studies, 1668 participants), fall-related hospitalisations (RR 0.96, 95% CI 0.87 to 1.06; 3 studies, 325 participants), or in the rate of falls requiring medical attention (RaR 0.91, 95% CI 0.58 to 1.43; 3 studies, 946 participants) (low-certainty evidence). The evidence for number of fallers requiring medical attention was unclear (2 studies, 216 participants; very low-certainty evidence). Two studies reported no adverse events. Assistive technology Vision improvement interventions may make little or no difference to the rate of falls (RaR 1.12, 95% CI 0.84 to 1.50; 3 studies, 1489 participants) or people experiencing one or more falls (RR 1.09, 95% CI 0.79 to 1.50) (low-certainty evidence). We are unsure of the evidence for fall-related fractures (2 studies, 976 participants) and falls requiring medical attention (1 study, 276 participants) because the certainty of the evidence is very low. There may be little or no difference in HRQoL (mean difference 0.40, 95% CI -1.12 to 1.92) or adverse events (falls while switching glasses; RR 1.00, 95% CI 0.98 to 1.02) (1 study, 597 participants; low-certainty evidence). Results for other assistive technology - footwear and foot devices, and self-care and assistive devices (5 studies, 651 participants) - were not pooled due to the diversity of interventions and contexts.  Education  We are uncertain whether an education intervention to reduce home fall hazards reduces the rate of falls or the number of people experiencing one or more falls (1 study; very low-certainty evidence). These interventions may make little or no difference to the risk of fall-related fractures (RR 1.02, 95% CI 0.96 to 1.08; 1 study, 110 participants; low-certainty evidence).  Home modifications We found no trials of home modifications that measured falls as an outcome for task enablement and functional independence. AUTHORS' CONCLUSIONS: We found high-certainty evidence that home fall-hazard interventions are effective in reducing the rate of falls and the number of fallers when targeted to people at higher risk of falling, such as having had a fall in the past year and recently hospitalised or needing support with daily activities. There was evidence of no effect when interventions were targeted to people not selected for risk of falling. Further research is needed to examine the impact of intervention components, the effect of awareness raising, and participant-interventionist engagement on decision-making and adherence.  Vision improvement interventions may or may not impact the rate of falls. Further research is needed to answer clinical questions such as whether people should be given advice or take additional precautions when changing eye prescriptions, or whether the intervention is more effective when targeting people at higher risk of falls. There was insufficient evidence to determine whether education interventions impact falls.

Radiographic technique modification and evidence-based practice: A qualitative study.

INTRODUCTION: Evidence-based practice in radiography is an emerging practice, due to a lack of evidence. Beyond the diagnostic requirements of the examination, imaging technique decisions are guided by the radiographer's tertiary education and clinical experience. Imaging technique decisions should include all aspects of evidence-based practice: research-based evidence, patient circumstances and clinical experience. Previous research suggests radiographers do to not fully engage with the latter, which may jeopardise progress in the field and lead to outdated practices and suboptimal outcomes for patients. This study aimed to examine the motivators and influences involved in radiographers' decision-making when modifying imaging acquisition techniques. METHODS: An exploratory descriptive, inductive qualitative interview-based design was used with a convenience sample of radiographers from three public hospital sites in Queensland. Twelve one-on-one semi-structured interviews were performed via video conference, the data were analysed through thematic analysis. RESULTS: Five themes emerged from the data: advancement of technology; experience rather than evidence; radiology's influence on radiographic practice; information sources; and image quality. The pursuit of image quality was the key motivator and criterion that influenced radiographers' choices in imaging technique modification. Interviewees did not engage routinely with research-based evidence, preferring to rely on empirical observations and professional experience. CONCLUSION: The exclusion of research-based evidence can lead to outdated and ineffective clinical decisions. Further work is needed to promote more research in the field of radiography and increase the willingness and capacity of radiographers to follow the principles of evidence-based practice.

Implementing best practice occupational therapist-led environmental assessment and modification to prevent falls: A qualitative study of two regional and rural public health services in Australia.

BACKGROUND: Occupational therapist-led environmental assessment and modification (EAM) is effective in reducing falls for populations at high risk. Two regional and rural public health services in Queensland devised an implementation strategy to embed best practice occupational therapist-led EAM. METHODS: A qualitative study was conducted to compare the determinants of implementation success across the different health services, using the COM-B model of behaviour change. Six semi-structured interviews were completed with occupational therapists involved at each site, following 12 months of implementation. Interview data were triangulated with minutes from three combined site steering committee meetings, eight local steering committee meetings, and field notes. Thematic analysis was completed to compare barriers and facilitators to best practice uptake of EAM and differences in outcomes between the two sites. RESULTS: Both sites commenced implementation with similar states of capability and motivation. After 12 months, one site considered that practice change had been embedded as noted in steering committee minutes and comments; however, the other site observed limited progress. According to the COM-B analysis, opportunity (the factors that lie outside the individual's control) had a significant influence on how both sites were able to respond to the practice change and navigate some of the unexpected challenges that emerged, including the COVID-19 pandemic. Existing team structure, multiple responsibilities of key stakeholders, differences in access to resources, and lack of connection between complementary services meant that COVID-19 disruptions were only a catalyst for unveiling other systemic issues. CONCLUSION: This study highlights the power of external factors on influencing behaviour change for best practice implementation. Learnings from the study will provide deeper understanding of completing implementation projects in regional and rural contexts and support the future implementation of EAM in occupational therapy clinical settings.

World guidelines for falls prevention and management for older adults: a global initiative.

BACKGROUND: falls and fall-related injuries are common in older adults, have negative effects on functional independence and quality of life and are associated with increased morbidity, mortality and health related costs. Current guidelines are inconsistent, with no up-to-date, globally applicable ones present. OBJECTIVES: to create a set of evidence- and expert consensus-based falls prevention and management recommendations applicable to older adults for use by healthcare and other professionals that consider: (i) a person-centred approach that includes the perspectives of older adults with lived experience, caregivers and other stakeholders; (ii) gaps in previous guidelines; (iii) recent developments in e-health and (iv) implementation across locations with limited access to resources such as low- and middle-income countries. METHODS: a steering committee and a worldwide multidisciplinary group of experts and stakeholders, including older adults, were assembled. Geriatrics and gerontological societies were represented. Using a modified Delphi process, recommendations from 11 topic-specific working groups (WGs), 10 ad-hoc WGs and a WG dealing with the perspectives of older adults were reviewed and refined. The final recommendations were determined by voting. RECOMMENDATIONS: all older adults should be advised on falls prevention and physical activity. Opportunistic case finding for falls risk is recommended for community-dwelling older adults. Those considered at high risk should be offered a comprehensive multifactorial falls risk assessment with a view to co-design and implement personalised multidomain interventions. Other recommendations cover details of assessment and intervention components and combinations, and recommendations for specific settings and populations. CONCLUSIONS: the core set of recommendations provided will require flexible implementation strategies that consider both local context and resources.

Home environmental assessments and modification delivered by occupational therapists to reduce falls in people aged 65 years and over: the OTIS RCT.

BACKGROUND: Falls and fall-related fractures are highly prevalent among older people and are a major contributor to morbidity and costs to individuals and society. Only one small pilot trial has evaluated the effectiveness of a home hazard assessment and environmental modification in the UK. This trial reported a reduction in falls as a secondary outcome, and no economic evaluation was undertaken. Therefore, the results need to be confirmed and a cost-effectiveness analysis needs to be undertaken. OBJECTIVE: To determine the clinical effectiveness and cost-effectiveness of a home hazard assessment and environmental modification delivered by occupational therapists for preventing falls among community-dwelling people aged ≥ 65 years who are at risk of falling, relative to usual care. DESIGN: This was a pragmatic, multicentre, modified cohort randomised controlled trial with an economic evaluation and a qualitative study. SETTING: Eight NHS trusts in primary and secondary care in England. PARTICIPANTS: In total, 1331 participants were randomised (intervention group, n = 430; usual-care group, n = 901) via a secure, remote service. Blinding was not possible. INTERVENTIONS: All participants received a falls prevention leaflet and routine care from their general practitioner. The intervention group were additionally offered one home environmental assessment and modifications recommended or provided to identify and manage personal fall-related hazards, delivered by an occupational therapist. MAIN OUTCOME MEASURES: The primary outcome was the number of falls per participant during the 12 months from randomisation. The secondary outcomes were the proportion of fallers and multiple fallers, time to fall, fear of falling, fracture rate, health-related quality of life and cost-effectiveness. RESULTS: The primary analysis included all 1331 randomised participants and indicated weak evidence of a difference in fall rate between the two groups, with an increase in the intervention group relative to usual care (adjusted incidence rate ratio 1.17, 95% confidence interval 0.99 to 1.38; p = 0.07). A similar proportion of participants in the intervention group (57.0%) and the usual-care group (56.2%) reported at least one fall over 12 months. There were no differences in any of the secondary outcomes. The base-case cost-effectiveness analysis from an NHS and Personal Social Services perspective found that, on average per participant, the intervention was associated with additional costs (£18.78, 95% confidence interval £16.33 to £21.24), but was less effective (mean quality-adjusted life-year loss -0.0042, 95% confidence interval -0.0041 to -0.0043). Sensitivity analyses demonstrated uncertainty in these findings. No serious, related adverse events were reported. The intervention was largely delivered as intended, but recommendations were followed to a varying degree. LIMITATIONS: Outcome data were self-reported by participants, which may have led to inaccuracies in the reported falls data. CONCLUSIONS: We found no evidence that an occupational therapist-delivered home assessment and modification reduced falls in this population of community-dwelling participants aged ≥ 65 years deemed at risk of falling. The intervention was more expensive and less effective than usual care, and therefore it does not provide a cost-effective alternative to usual care. FUTURE WORK: An evaluation of falls prevention advice in a higher-risk population, perhaps those previously hospitalised for a fall, or given by other professional staff could be justified. TRIAL REGISTRATION: Current Controlled Trials ISRCTN22202133. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 46. See the NIHR Journals Library website for further project information.

Falling is a common problem among older people. In fact, up to half of people aged over 80 years fall each year, with most falls happening inside the home. Unfortunately, some falls cause serious injuries, such as broken bones. People often think that falls are part of getting older and that little can be done to stop them from falling. However, there are many ways to reduce falls. The Occupational Therapist Intervention Study (OTIS) explored whether or not a home assessment visit by an NHS occupational therapist could reduce falls among older people who are likely to be at risk of falling. In total, 1331 people aged 65 years or older living in England took part in the study. These people were all sent an Age UK leaflet about how to prevent falls, and 430 people were selected at random to receive a visit from an occupational therapist. The occupational therapist assessed their homes for hazards, such as slippery floors or poor lighting, and made suggestions for changes. We collected information from participants using monthly falls calendars and postal questionnaires to ask them about their falls, their quality of life, how often they used NHS services and how often they used paid care workers. We also asked them about whether they had had equipment and adaptations installed as a result of the assessments. We found that the home assessment visits did not reduce the number of falls people had or make any difference to participants' quality of life. However, many of the recommendations made by the occupational therapists were not carried out. The home assessment visits by an occupational therapist were not good value for money.

Promoting Interprofessional Education and Collaborative Practice in Rural Health Settings: Learnings from a State-Wide Multi-Methods Study.

Evidence is mounting regarding the positive effects of Interprofessional Education and Collaborative Practice (IPECP) on healthcare outcomes. Despite this, IPECP is only in its infancy in several Australian rural healthcare settings. Whilst some rural healthcare teams have successfully adopted an interprofessional model of service delivery, information is scarce on the factors that have enabled or hindered such a transition. Using a combination of team surveys and individual semi-structured team member interviews, data were collected on the enablers of and barriers to IPECP implementation in rural health settings in one Australian state. Using thematic analysis, three themes were developed from the interview data: IPECP remains a black box; drivers at the system level; and the power of an individual to make or break IPECP. Several recommendations have been provided to inform teams transitioning from multi-disciplinary to interprofessional models of service delivery.

The Impact of Endoscopy Sedation Information Sheets on the Level of Concern Regarding Possible Awareness in Patients Undergoing Endoscopy Sedation.

Sedation encompasses a continuum from complete unconsciousness to drowsiness and anxiolysis where some awareness might be expected. Most patients undergoing endoscopy sedation expect to be completely unconscious during the procedure and thus have unmet expectations regarding their state of consciousness. This study aimed to evaluate whether endoscopy sedation information sheets reduce the level of concern regarding possible awareness during endoscopy sedation at a major regional hospital. Our findings were that 28.8% of patients who received the endoscopy sedation information sheet (n = 82) were concerned about awareness during the procedure, compared to 36.5% of patients in the control group (n = 105). However, the difference was not statistically significant. We also found that the incidence of awareness was higher (13.9%) in the intervention group compared to 8.8% in the control group but, again, not statistically different. This study allowed us to elucidate the level of concern regarding possible awareness during sedation and the incidence of awareness during endoscopy sedation. This will enable future work investigating the role of endoscopy sedation information methods involving written and video material in assisting pre-procedure patient counselling.

Occupational therapist led environmental assessment and modification to prevent falls: Review of current practice in an Australian rural health service.

INTRODUCTION: Environmental assessment and modification is an effective approach to reducing falls, particularly when provided by occupational therapists to high risk populations. Environmental assessment and modification has been incorporated into many national and international falls prevention guidelines, however, evidence suggests that it is not being implemented in practice. The aim of this study is to identify factors that support the local adoption of best practice environmental assessment for falls prevention within a rural health service. METHODS: A concurrent mixed methods study using the Integrated Promoting Action on Research Implementation in Health Services framework was employed. The setting was a health service in Queensland, encompassing rural and regional populations. An audit, based on best practice, was conducted on eligible medical charts. An online survey of occupational therapists' knowledge, attitudes, confidence and experience of environmental assessment and modification was completed. Focus group discussions were also carried out. Quantitative data were presented using descriptive statistics and discussions were thematically analysed. RESULTS: Twenty-four occupational therapists were identified as meeting the inclusion criteria. Fourteen participated in the survey and 12 of those surveyed also participated in the focus groups. Fifty-eight patients' medical charts were audited, which included entries from occupational therapists who completed the survey and focus groups and some who did not. Survey results identified that most occupational therapists were aware of, confident, and experienced in environmental assessment and modification for falls prevention. Chart audits, however, revealed that none of the patients received this intervention. Thematic analysis of focus group discussions identified three key themes which influenced uptake of environmental assessment and modification: confidence in, and awareness of evidence; key stakeholders' support and knowledge of occupational therapy; and, perceived impact of time and resources required for implementation. Results also suggested that several contextual issues unique to rural and regional service delivery influenced uptake, including: geographical and sociocultural diversities of communities being served; differing organisational structures which result in occupational therapists being line managed by other professions; and, limited access to professional development. Availability of local peer support, and engagement of multiple stakeholders from various professions were highlighted as key facilitators to support change. CONCLUSION: Occupational therapists reported that they carried out best practice environmental assessment and modification for falls prevention but the medical chart audit provided no evidence of this happening in practice. This discrepancy requires further investigation. This study provided an understanding of factors that influence whether occupational therapists implement best practice environmental assessment and modification in a rural health service. Findings could be used to guide the translation of evidence into practice across similar settings.

Can occupational therapist-led home environmental assessment prevent falls in older people? A modified cohort randomised controlled trial protocol.

INTRODUCTION: Falls and fall-related injuries are a serious cause of morbidity and cost to society. Environmental hazards are implicated as a major contributor to falls among older people. A recent Cochrane review found an environmental assessment, undertaken by an occupational therapist, to be an effective approach to reducing falls. However, none of the trials included a cost-effectiveness evaluation in the UK setting. This protocol describes a large multicentre trial investigating the clinical and cost-effectiveness of environmental assessment and modification within the home with the aim of preventing falls in older people. METHODS AND ANALYSIS: A two-arm, modified cohort randomised controlled trial, conducted within England, with 1299 community-dwelling participants aged 65 years and above, who are at an increased risk of falls. Participants will be randomised 2:1 to receive either usual care or home assessment and modification. The primary outcome is rate of falls (falls/person/time) over 12 months assessed by monthly patient self-report falls calendars. Secondary self-reported outcome measures include: the proportion of single and multiple fallers, time to first fall over a 12-month period, quality of life (EuroQoL EQ-5D-5L) and health service utilisation at 4, 8 and 12 months. A nested qualitative study will examine the feasibility of providing the intervention and explore barriers, facilitators, workload implications and readiness to employ these interventions into routine practice. An economic evaluation will assess value for money in terms of cost per fall averted. ETHICS AND DISSEMINATION: This study protocol (including the original application and subsequent amendments) received a favourable ethical opinion from National Health Service West of Scotland REC 3. The trial results will be published in peer-reviewed journals and at conference presentations. A summary of the findings will be sent to participants. TRIAL REGISTRATION NUMBER: ISRCTN22202133; Pre-results.

Prevalence of unjustified emergency department x-ray examination referrals performed in a regional Queensland hospital: A pilot study.

INTRODUCTION: The underpinning principles of radiation protection are justification, optimisation and limitation. Each medical imaging referral that uses ionising radiation must balance the justification of exposure to radiation against the benefits of the examination. Scrutiny of justification is the role of radiographers, for general radiography, and is usually performed using the clinical details provided on the referral. International studies report up to 77% of medical imaging examinations are unjustified or inappropriate. In regional Queensland, justification seems to involve a subjective assessment and enforcement is ad hoc. This study aimed to determine the number of unjustified emergency department x-ray examinations performed in a regional Queensland hospital. METHODS: An audit of the clinical details provided on x-ray referrals and in the medical records was performed on x-ray examinations undertaken within an 11-day period. Justification was determined by compliance with the Government of Western Australia's diagnostic imaging pathways. RESULTS: Of the 186 referrals assessed, 75.3% were categorised as not having complied with the imaging pathway and were considered unjustified. When the clinical details in the patient's medical record were reviewed, in conjunction with the referral, the unjustified rate reduced to 49.2% of examinations. CONCLUSION: Results demonstrate a lack of information transfer by referring clinicians and a lack of compliance with justification requirements for imaging by medical imaging staff. Improved communication regarding the need for imaging, and the refusal of referrals that are not justified, will ensure that patients are only exposed to radiation when clear benefit has been demonstrated.

Improving education and supervision of Queensland X-ray Operators through video conference technology: A teleradiography pilot project.

INTRODUCTION: X-ray Operator (XO) supervision in Queensland is performed by radiographers in a site removed from the XO site. This has historically been performed by telephone when the XO requires immediate help, as well as post-examination through radiographer review and the provision of written feedback on images produced. This project aimed to improve image quality through the provision of real-time support of XOs by the introduction of video conference (VC) supervision. METHODS: A 6-month pilot project compared image quality with and without VC supervision. VC equipment was installed in the X-ray room at two rural sites, as well as at the radiographer site, to enable visual and oral supervision. The VC unit enabled visualisation of the X-ray examination technique as it was being undertaken, as well as the images produced prior to transmission to the Picture Archiving and Communication System (PACS). RESULTS: Statistically significant improvement in image quality criteria measures were seen for patient positioning (P = 0.008), image quality (P < 0.001) and diagnostic value (P < 0.001) of images taken during this project. No statistically significant differences were seen during case level assessment in the inclusion of only appropriate imaging (P = 0.06), and the inclusion of unacceptable imaging (P = 0.06), however improvements were seen in both of these criteria. The survey revealed 24.6% of examinations performed would normally have involved the XO contacting the radiographer for assistance, although, assistance was actually provided in 88.3% of examinations. CONCLUSION: This project has demonstrated that significant improvement in image quality is achievable with VC supervision. A larger study with a control arm that did not receive direct supervision should be used to validate the findings of this study.

Randomised controlled trial of a transprofessional healthcare role intervention in an acute medical setting.

As demand for health services increases, attention has turned to the development of alternate models of service delivery that maximise efficiency. These include skill sharing models, in which cross-professional skills are delivered by appropriately trained professionals. The usage of skill sharing models is increasing in some professions, but little evidence on efficacy currently exists. This article reports on an intervention of the use of a transprofessional role, which involved delivery of services from a range of health providers, including physiotherapy, occupational therapy, dietetics, speech pathology, podiatry, social work, and psychology, by a trained professional, developed and trialled in the acute medical setting in Toowoomba Hospital, Queensland, Australia. A single-blind randomised controlled trial examined the clinical efficacy of this skill shared service. Participants were allocated at random to either standard care (n = 29) or the new model of care (n = 29) groups and compared on a range of patient and service provision outcome measures. Descriptive outcomes indicated that patients receiving the new model of care underwent more comprehensive and prompt assessments in the health domains included than those in standard care, and demonstrated more positive health and functional outcomes at 1-, 3-, and 6-month follow-up. Given the paucity of research on skill sharing, this study provides preliminary evidence of the effectiveness of skill shared roles in acute settings.

Implementation of a new model of clinical education for regional occupational therapy student clinical placements.

Expansion of occupational therapy education programs has resulted in increased student numbers and demand on clinicians to host clinical placements while also maintaining the delivery of high-quality, safe clinical services to patients. Much of the research about innovative placement models, including student contributions to service delivery, has been conducted in metropolitan areas. Therefore, there is a need to develop models that are suited to regional settings that face diversity of caseload, more generalised occupational therapy roles and variations in patient flow. The aim of the present study was to describe the initial application of the Calderdale Framework in student education in a regional context and look at lessons learnt. The Calderdale Framework provided a structured, clinically governed process whereby occupational therapists were able to determine which tasks could be allocated to students and provided a framework to support student training and competency development. The Calderdale Framework has been used successfully to implement allied health models involving professional skill sharing and delegation of tasks to allied health assistants, but it has not been used in clinical education. Pilot implementation of the Calderdale Framework showed that the model supports quality and safety of student-provided occupational therapy services and that the teaching method provides a platform for student skill development. These results warrant further investigation and are potentially transferrable to student education in other health professions.

Comparison of research experience and support needs of rural versus regional allied health professionals.

OBJECTIVE: We compared the research experience or support needs of allied health professionals in rural versus regional cities to identify if they were the same or different. DESIGN: Descriptive study using a cross sectional survey. SETTING: This study was carried within Queensland Health's northern six health services. PARTICIPANTS: Queensland health staff classified as Health Practitioners. INTERVENTIONS: This survey was conducted as part of a research capacity building initiative within Queensland Health to increase AHPs' participation in research in regional cities and rural areas of Queensland. MAIN OUTCOME MEASURES: Questions in the survey identified demographics, research experience, need for research support, research knowledge and beliefs about research. Data were compared using Chi-square and t-tests. RESULTS: The total response rate was 54.5% with 18% of the HPs located in rural communities of less than 5000 people and the rest from the three major cities in northern Queensland. Rural HPs have less research experience in most research activities than regional city HPs and need more research support. Rural HPs have more qualitative research experience than regional city HPs and research is perceived positively by both. Barriers to conducting research were similar across both groups and included insufficient time, lack of staff and no statistical support. CONCLUSION: Rural HPs are younger and have less research experience than their counterparts working in regional cities. Therefore, building rural HP research capacity initiatives may require more access to facilitators such as the Research Fellows.

Positioning occupational therapy as a discipline on the research continuum: results of a cross-sectional survey of research experience.

BACKGROUND/AIM: Evidence-based practice and research are beginning and endpoints on a research continuum. Progression along the continuum builds research capacity. Occupational Therapy has a low evidence base, thus, clinicians are not implementing evidence-based practice or publishing research. Barriers to implementing evidence-based practice and engaging in research include a lack of confidence. This research gauged Occupational Therapists' research experience, support needs and barriers, and compared levels of research anxiety between allied health disciplines. METHODS: A cross-sectional survey was sent to Health Practitioners in northern Queensland in May-June 2011. Responses about experience, support needs and barriers, between Occupational Therapists, were analysed using Chi-square 'goodness of fit' tests. Multivariate analysis compared responses between disciplines about research anxiety. This paper reports results for the subset of Occupational Therapists. RESULTS: The whole population, consisting of 152 Occupational Therapists, was sent a questionnaire, from which 86 responded. More Occupational Therapists than not had experience of evidence-based practice and less support was required, but they had little experience of producing research and required more support. The amount of support required for activities along the research continuum was inversely related to the level of experience in these tasks. Barriers included lack of staff and time. Occupational Therapists were more anxious about research (53 of 79, 67%) than all other Health Practitioner disciplines combined (170 of 438, 39%, P < 0.0001). CONCLUSION: A cohesive strategy should focus on consolidating Occupational Therapists' evidence-based practice skills and building confidence. Clinicians wishing to engage in research need access to academic support. Academics and clinicians should work closely to produce clinically relevant research.

Assessing the implementation process and outcomes of newly introduced assistant roles: a qualitative study to examine the utility of the Calderdale Framework as an appraisal tool.

Internationally, the health workforce has undergone rapid transformation to help meet growing staffing demands and population requirements. Several tools have been developed to support workforce change processes. The Calderdale Framework (CF) is one such tool designed to facilitate competency-based training by engaging team members in a seven step process involving awareness raising, service and task analysis, competency identification, establishing support systems, training, and sustaining. This paper explores the utility of the CF as an appraisal tool to assess whether adherence to the tool influences outcomes. The CF was applied retrospectively to three complete evaluations of allied health assistant role introduction: a new podiatry assistant role (Australia), speech pathology assistant (Australia), and occupational therapy assistant practitioner role (UK). Adherence to the CF was associated with more effective and efficient use of the role, role flexibility and career development opportunities for assistants, and role sustainability. Services are less likely to succeed in their workforce change process if they fail to plan for and use a structured approach to change, assign targeted leadership, undertake staff engagement and consultation, and perform an initial service analysis. The CF provides a clear template for appraising the implementation of new roles and highlights the potential consequences of not adhering to particular steps in the implementation process.

Environmental assessment and modification to prevent falls in older people.

UNLABELLED: To assess the effectiveness of an environmental falls prevention intervention delivered by qualified occupational therapists or unqualified trained assessors. DESIGN: A pilot three-armed randomized controlled trial. SETTING: Airedale National Health Service Trust catchment, North and West Yorkshire, England. PARTICIPANTS: Two hundred thirty-eight community-dwelling adults aged 70 and older with a history of falls in the previous year. INTERVENTION: Assessment and modification of the home environment of people at greater risk of falls. MEASUREMENTS: Fear of falling was the primary outcome measure, and an analysis of covariance was conducted on the area under the curve at 12 months. As a secondary outcome, falls were analysed using negative binomial regression. Quality of life and independence in activities of daily living (ADLs) were also measured. RESULTS: The intervention had no effect on fear of falling (P=.63). The occupational therapy group had significantly fewer falls than controls 12 months after the assessment (incidence rate ratio (IRR)=0.54, 95% confidence interval (CI)=0.36-0.83, P=.005). There was no significant effect on falls in the trained assessor group (IRR=0.78, 95% CI=0.51-1.21, P=.34). CONCLUSION: Environmental assessment had no effect on fear of falling. Environmental assessment prescribed by an occupational therapist significantly reduced the number of falls in high-risk individuals whereas that prescribed by a trained assessor did not. Further research in other settings is needed to confirm this, to explore the mechanisms, and to estimate cost-effectiveness.

Publicity does not increase recruitment to falls prevention trials: the results of two quasi-randomized trials.

OBJECTIVE: To test the effect of publicity on recruitment to a randomized trial. Recruitment is often poor in trials. Publicity within recruitment packs might be an inexpensive method of increasing recruitment. We tested this in two quasi-randomized trials. STUDY DESIGN: In a primary care setting, within the context of a randomized trial of falls prevention, we allocated participants to receive a newspaper article about the study with their information sheet. The first trial compared one newspaper article against no article; the second compared a more favorably written article against the original. RESULTS: In the first study 4,488 participants were allocated into two groups. The response rate was 102 and 97 in the intervention and control groups, respectively (4.55% vs. 4.32%, 95% confidence interval [CI]: -0.98, 1.43); the recruitment rate was 73 and 71, respectively, the difference not being statistically significant. In the second study 2,745 were allocated into two groups with a response rate of 75 and 69 for the control and intervention groups, respectively (5.46% vs. 5.03%, 95% CI: -1.24, 2.09); the recruitment rate was 57 and 54, respectively, the difference not being statistically significant. CONCLUSION: These two large experiments revealed no evidence of effect of publicity on recruitment rates.

Pre-discharge home visits with older people: time to review practice.

The present review paper uses the available evidence to make a case for a reconsideration of the practice of undertaking pre-discharge home visits with frail older people as part of decisions regarding a return home. This practice is embedded into the routine activity of acute medical wards for older people and occupies a large proportion of the time of hospital employed therapy staff, with consequent financial and resource implications. Assessments are often conducted to provide information on safe discharge rather than being located in the interests of the older person and their carer. The introduction of a new range of services bridging hospital and home raises the need for an urgent, critical appraisal of this practice.