An evaluation of the fall prevention practice of community-based occupational therapists working in primary care

Abstract

Introduction

Occupational therapy in primary care settings in Australia is developing. This study aimed to examine current practice in preventing falls among older people living in the community prior to attending a home safety workshop; explore the outcomes of the workshop on fall prevention practice; and investigate self-reported changes in practice 3 months after the workshop.

Method

The 3-hour workshop was focused on evidence-based home safety interventions and was offered to occupational therapists providing community-based services in the Sydney North Primary Health Network area. Knowledge surveys were used immediately pre and post workshop, and practice surveys were collected data at baseline and at 3-month follow-up.

Results

Three workshops were run in 2015–2016, with a total of 40 occupational therapists. At follow-up, a positive impact on confidence and knowledge was reported. Less impact was observed on identifying and reducing an older person’s fall risk, and on fall prevention services provided and referrals received. Changes in practice were reported by 48% (n = 16) of the 33 participants who returned surveys at 3 months.

Conclusion

These findings provide support for the benefit of professional development workshops to improve confidence and knowledge, but challenges remain in facilitating change in fall prevention service delivery. Further study on screening for fall risk and collaboration between community service providers in the primary care context is recommended.

Keywords

Accidental falls allied health occupations community-residing

Introduction

Falls are a prominent cause of injury and reduced quality of life among older individuals, an issue that is familiar to many health professionals. Occupational therapists are key providers of effective fall prevention interventions, especially in the community (Royal College of Occupational Therapists, 2015; Peterson and Clemson, 2008). Professionals in the primary care context, including general practitioners (GPs) and other allied health providers (AHP), are particularly well placed to offer primary prevention services to older people at risk of falls. In Australia, the health system consists of a mix of publicly and privately funded services administered by several levels of government (national, state/territory and local) and is supported by private health insurance arrangements. In primary health and community services, all GPs and most AHP are private practitioners (Australian Bureau of Statistics, 2012). The Integrated Solutions for Sustainable Fall Prevention (iSOLVE) project is an ongoing partnership between the University of Sydney, the New South Wales Clinical Excellence Commission and the North Sydney Primary Health Network (NSPHN). The project aims to develop a healthcare model that facilitates increased communication between GPs and community service providers, including occupational therapists, to allow for greater partnership in fall prevention interventions (Clemson et al., 2017). This study reports on findings of data collected from occupational therapists working in primary care about their fall prevention practice and the outcomes of a series of professional development workshops offered in evidence-based home safety interventions.

Literature review

Falls are the second leading cause of death from accidents and injury worldwide; a fall is defined as ‘in-advertently coming to rest on the ground, floor or other lower level’ (World Health Organization, 2008: p.1). Older people aged 65 and over are at highest risk of falling, with 30% of people over 65 years and 50% of people over 80 years falling each year (Australian Commission on Safety and Quality in Healthcare, 2009; National Institute for Health and Care Excellence, 2013). Injuries associated with hospitalisation due to falls include hip fractures, traumatic brain injuries and injuries to the upper limb (World Health Organization, 2008). In addition to consequences for the individual, the costs of falls are estimated at £2 billion a year for UK healthcare services (Royal College of Physicians, 2010), and at AU$648 million a year in acute care alone in Australia (Bradley, 2012). Falls are complex in nature and are affected by behavioural, biological, socioeconomic and environmental risk factors (Deandrea et al., 2010). Knowledge of these factors is essential in enabling recognition of at-risk individuals and intervening before a fall or injury occurs. There is a substantial body of literature showing the effectiveness of interventions in reducing fall risk and incidence in trial environments. A comprehensive Cochrane review found strong evidence for a number of exercise interventions, and also supported interventions related to home safety and medication reviews (Gillespie et al., 2012).

These evidence-based fall prevention interventions are typically provided by AHP; however, despite numerous studies demonstrating a reduction in fall risk or incidence, there appear to be barriers in implementing this evidence in the community. In Australia, age-standardised rates of falls have increased by 2.4% per year from 1999 to 2012 (Pointer, 2015). Therefore, the current evidence available about effective fall prevention has not reduced falls within the community. There appears to be a gap in the implementation of these fall prevention strategies in daily practice. Knowledge translation refers to the process of promoting the use of current evidence and recommendations by health professionals in their practice (Pentland et al., 2011). Knowledge translation frameworks have been developed to support the provision of education on current evidence and translating this into practice. Some of the explanation for the implementation gap may be that health professionals have difficulty in accessing good-quality research literature and then translating fall prevention evidence into practice (Child et al., 2012; Mackenzie, 2009). Further to this, little is known about the current practice of health professionals in fall prevention, particularly occupational therapy.

The development of the iSOLVE project in Australia (Clemson et al., 2017) seeks to address the apparent difficulty in translating knowledge about successful methods to prevent falls in the primary care setting. To improve access to multi-disciplinary fall prevention interventions for older people in primary care, one of the project aims is to facilitate sustainable knowledge acquisition among GPs and AHP. The overall AHP iSOLVE intervention comprised three components: (i) an interactive workshop; (ii) planning for implementation and sustainability; and (iii) facilitation of referral networks. The interactive workshops were based on findings from a Cochrane review on the effectiveness of educational workshops (Forsetlund et al., 2009), and the Knowledge to Action Framework (Graham et al., 2006) was used to guide the planning for the overall AHP component of the study. This framework is a process model that describes the process of translating research into practice through stages of identifying knowledge, adapting knowledge to the local context, assessing barriers to using knowledge, tailoring and implementing interventions, monitoring and sustaining the use of knowledge and evaluating outcomes (Field et al., 2014; Nilsen, 2015).

The workshops were developed with the goal of disseminating best practice guidelines and evidence to community AHP, to enable practice change, provide more effective services and ultimately lead to decreased falls in the community. An understanding of current fall prevention practice among AHP was also important to guide the design and implementation of ongoing workshops. This particular study focused on fall prevention undertaken by occupational therapists in order to identify any professional issues in fall prevention provision specific to occupational therapy. The study aimed to (i) explore their understanding of evidence-based fall prevention; (ii) examine their current practice in preventing falls among older people living in the community prior to attending a home safety workshop, and (iii) to identify any perceived changes in practice among occupational therapists following their participation in the workshop after 3 months.

Method

A one-group, prospective, pre-post survey design (Portney and Watkins, 2000, p.193) was used to explore the practice and perceptions of workshop participants before and after their participation in a home safety professional development workshop. This method involves a set of measures (in this case, a survey) being taken before and after an intervention with one group of participants.

Ethics approval

The study was carried out within the North Sydney Local Health District, which is the geographical area covered by NSPHN. Ethics approval was granted by the University of Sydney Human Research Ethics Committee (#2014/316). All workshop registrants were provided with a participant information statement about the study embedded in the online survey, and were asked to return a survey prior to the workshop and 3 months after the workshop. Return of a completed survey was voluntary and participants indicated their consent online prior to accessing the survey. Although some study participants may have been known to the researchers, all survey responses were anonymous, and individual responses could not be linked to individual participants.

Sample size

To estimate the sample size for this study, the only directory of occupational therapy private practices that is currently available on the Occupational Therapy Australia website was used. Thirty-three practices were identified that indicated that they specialised in older people and fall prevention in the NSPHN geographical area. This may underestimate the sample size as some private practitioners may not be members of Occupational Therapy Australia, and this directory only lists the number of practices, not the number of occupational therapists working for the practice. However, this data does give some indication of the size of the sample from which this study was drawn.

Recruitment for workshops

Free workshops were provided to occupational therapists working in fall prevention in primary health services within the community. A number of recruitment methods were used to increase reach within the target demographic. Eligibility criteria for workshop attendance were that the occupational therapist had to work within the target geographical area, provide services to community patients, and receive or have the capacity to receive GP referrals. All participants who registered were screened for these eligibility criteria before being admitted to a workshop.

The primary method of recruitment was via an advertisement circulated by the NSPHN to members who received the organisation’s regular newsletter. In addition, direct contact was made to occupational therapists identified through service provider listings on the websites of relevant professional organisations, internet searching using key words related to occupational therapy, and utilising the Google map feature to identify services within the target district. In addition, occupational therapists were identified by GPs if they referred to them, and through a surveillance of services surrounding the location of any GP practice recruited into a parallel randomised controlled trial run by the iSOLVE project. The final process was through snowballing by word of mouth.

Workshops

Three workshops were offered focusing on effective home safety interventions. The workshop was designed and led by experts in home safety (L.C. and L.M.). Home safety interventions are supported by numerous studies and reviews indicating a reduction in fall risk and frequency in older individuals (Clemson et al., 2008; Gillespie et al., 2012; James et al., 2014; Pighills et al., 2016). Each workshop was run in cooperation with NSPHN and was held at a range of function venues within the geographical region of the NSPHN. Workshop delivery was interactive and consisted of presentations with opportunity for group case studies and problem-solving. Supplementary educational and reference material was provided to all participants. In line with the Knowledge to Action Framework (Field et al., 2014), the workshop content involved a presentation of current evidence (identifying knowledge), working on case studies (adapting knowledge to the local context), and participants sharing what is needed for effective implementation in their setting (assessing barriers to using knowledge, tailoring and implementing interventions). Responses to the implementation exercise were then summarised and distributed to participants after each workshop. Participants were also asked during the workshop whether they wished to be formally linked to GPs to receive direct referrals for fall prevention.

Data collection

Workshop participants were invited to participate in the study by completing in-depth practice surveys before the workshop (baseline) and at 3-month follow-up. Surveys were sent electronically to participants upon enrolling in a workshop. At follow-up, a reminder to complete the survey was emailed for three consecutive weeks, followed by a paper copy of the survey, and finally a direct call was made to request participants to complete the follow-up survey.

Surveys were developed by the research team to address known practice issues in fall prevention identified in the literature. Surveys consisted of 14 items addressing attitudes, difficulties, confidence, assessments and interventions related to fall prevention practice, as well as services provided and communication with other health professionals and service providers. Items were related to three of the Knowledge to Action Framework elements outlined in Table 1 (adapt knowledge to local context; assess barriers to knowledge use; and select, tailor and implement interventions). Questions predominantly used four- and five-point Likert scales (depending on whether a neutral response was not desired), but also included some open-ended items, allowing for further comments and listing of current assessments and interventions used in practice by the participants. Follow-up surveys were identical to baseline surveys with the addition of an item assessing perceptions about any change in practice since the workshop. Electronic surveys were administered utilising the browser-based electronic data software Research Electronic Data Capture (REDCap). Surveys were piloted among research team contacts prior to distribution to ensure accurate interpretation and responses.

Table 1.

Outline of survey items according to the knowledge to action framework (Field et al., 2014).

Knowledge to Action framework element	Survey items
• Adapt knowledge to local context	• Demographic information • Service sector (self-employed, working for a private practice, private health service, public health service) • Employment status (full time, part time, contract, continuing) • Patients seen (over 65 years old, at risk of falls)
• Assess barriers to knowledge use	• Personal attitudes to fall prevention (can older people improve their ability to identify fall risk, and is it possible to reduce risk of falling?) • Funding of services • Source of referrals (GP, geriatrician, community nurse, physiotherapist, exercise physiologist, other occupational therapists, pharmacist, optometrist/ophthalmologist, podiatrist, community exercise class, Stepping On, fall clinic, self-referral) • Confidence in providing home environmental interventions, involving older people in joint decision-making, and developing solutions with older people to change habits or their environment to reduce falls
• Select, tailor and implement interventions	• Falls prevention management (frequency of screening for falls, assessing for falls, implementing fall prevention interventions and receiving referrals for fall prevention) • Frequency of sourcing evidence-based information, receiving/seeking referrals, engaging with a GP, liaising with other fall prevention providers, referring to other fall prevention providers, assessing fall risk, managing fall risk factors and discussing falls prevention • Assessments used • Interventions used

Knowledge surveys were also used during the workshops to gather information related to the ‘identify, review and select knowledge’ element of the Knowledge to Action Framework (Field et al., 2014). These consisted of six multiple-choice questions, including items on knowledge of fall risk factors related to home safety, and on prioritising groups of intervention strategies according to the evidence. Items were generated by the members of the research team who were presenting the workshop content. Surveys were completed in person by participants immediately before the workshop began, so that participants could identify any gaps in their knowledge, and were repeated immediately after the workshop to determine whether any change in knowledge had taken place following the presentation of workshop content.

Data analysis

The Statistical Package for the Social Sciences (SPSS) version 24 was used to compile and analyse all study data. Descriptive statistics using percentages and frequencies, and chi-square analyses were used to compare groups pre and post workshop. Some four- and five-point Likert scales were dichotomised for clarity; for instance, ratings of self-confidence were dichotomised to form two items – ‘less confident’ (‘not at all confident’ and ‘a little confident’) and ‘more confident’ (‘quite confident’ and ‘very confident’) – and were analysed using χ2 to determine any differences. Correct responses on the knowledge surveys pre and post the workshop were also analysed using descriptive analyses. Assessment items reported by participants using free text responses were compiled into three categories – ‘no assessment used’, ‘standardised assessment’ and ‘non-standardised or falls screen’. Some participants reported multiple assessments, and each assessment was coded separately, resulting in multiple counts. Participants also recorded their fall interventions qualitatively via an open-ended question. These results were then interpreted by the authors and coded into key categories based on modality and type. Some participants reported multiple intervention approaches; in these instances, each individual intervention was coded separately.

Results

Three home safety workshops were run between April 2015 and April 2016. Workshops were attended by 40 individual occupational therapists, and 31 completed baseline surveys (77.5%). Three-month follow-up surveys were completed by 33 participants (82.5%). Both surveys were anonymous, so it was not possible to track individual changes over time.

Most participants worked in a public health service (n = 9, 31.0%), in a private health service or hospital (n = 9, 31.0%), or in a private practice (n = 8, 27.5%). The remainder worked in residential care facilities or non-governmental agencies (such as a charity or community-funded organisation). Most worked full-time (n = 14, 48.3%) or part-time (n = 9, 31.0%), with the remainder working casually or on contract. Participants indicated that funding for their service was provided via public health services (n = 11, 35.5%), private services (n = 5, 16.1%), payment by the client (n = 5, 16.1%), Department of Veterans Affairs (n = 5, 16.1%), private health insurers (n = 5, 16.1%), non-governmental organisations (n = 3, 10.0%) or chronic disease management programmes with the GP (n = 1, 3.2%).

Participant understanding of evidence-based fall prevention

The mean number of correct answers to the six multiple choice knowledge questions before the workshop was 4.24, compared with 4.90 after the workshop. A chi-square analysis of correct responses before and after the workshop indicated a significant improvement (χ2 (16) = 30.7 p = 0.015).

Fall prevention practice prior to the workshop and at follow-up

Attitudes to fall prevention

All participants reported believing that it was possible to identify fall risk and reduce an individual’s risk of falling to some degree. Of the 29 participants who responded to these items at baseline, 96.6% (n = 28) believed it was possible to improve an older person’s ability to identify their risk of falling in their home environment to a ‘moderate’ or ‘great’ extent at baseline, with no significant change in this belief at 3 months following the workshop (93.9%, n = 31). Similarly, participants believed it was possible to reduce the risk of falling for an older person, with no significant change after the workshop (baseline 96.6%, n = 28; 3 months 94.0%, n = 31).

Confidence in providing fall prevention services

There were significant improvements in self-rated confidence from baseline to follow-up for conducting home environmental interventions to reduce the risk of falling with older people aged 65 + (χ2 (3) = 10.02, p = 0.018), for involving older people in joint decision-making and prioritising home hazards (χ2 (3) = 20.49, p = 0.001), and for developing solutions with older people to change their habits or environments to reduce their risk of falling (χ2 (3) = 29.96, p = 0.001).

Referrals received for fall prevention services

Figure 1 outlines the frequency of referrals made to occupational therapists at baseline and follow-up. Persistent low levels of referrals were received from exercise physiologists, pharmacists, optometrists and ophthalmologists, podiatrists, community exercise classes, Stepping On programmes and falls clinics at both baseline and 3 months. Only 32% of participants indicated that they often received referrals from GPs at baseline, and this reduced to 4% at follow-up. Referrals from GPs, geriatricians, community nurses, physiotherapists and self-referrals were the most frequent at baseline and follow-up.

Fall prevention services provided

Figure 1.

Referrals to occupational therapy at baseline and follow-up.

Participants reported that they screened for fall risk, assessed for fall risk and provided fall prevention interventions less often at 3 months compared with baseline (see Figure 2).

Fall prevention assessments used

Figure 2.

Fall prevention services provided at baseline (n = 31) and at 3 months post workshop (n = 33).

At baseline, nine participants (29%) indicated that they did not use any assessments, and at follow-up this increased to 13 participants (39.4%). The use of non-standardised assessments decreased from baseline to follow-up, although these were still used by most participants at baseline (n = 14, 42.4%) and follow-up (n = 13, 39.4%).

At baseline, 35.5% (n = 11) of participants indicated that they used at least one standardised assessment. The most commonly used standardised tools were the Timed Up-and-Go test (n = 4) (Podsiadlo and Richardson, 1991), the Berg Balance Scale (n = 3) (Berg et al., 1992), the Home Falls and Accidents Screening Tool (n = 3) (Mackenzie et al., 2000), and the Ontario Modified Stratify Tool (n = 2) (Neuroscience Research Australia, 2012). At follow-up, the most commonly used standardised tools identified were the Timed Up-and-Go test (n = 2) (Podsiadlo and Richardson, 1991), the Ontario Modified Stratify Tool (n = 2) (Neuroscience Research Australia, 2012), the Fall risk for Older People – Community (FROP-Com; n = 2) (Russell et al., 2008), the Falls Efficacy Scale (n = 2) (Tinetti et al., 1990), and the Westmead Home Safety Assessment (n = 2) (Clemson et al., 1999).

Fall prevention interventions used

Table 2 outlines the fall prevention interventions reported by workshop participants at baseline and follow-up. Between 16 and 24% of participants reported providing no interventions at baseline or follow-up. Reductions were observed in the proportions of participants providing education and implementing home modifications from baseline to follow-up, whereas increases were observed in the provision of assistive devices, referrals to other services, transfer training and exercise provision at follow-up.

Reported difficulties in fall prevention practice

Table 2.

Fall prevention interventions reported by participants at baseline and follow-up.

	Baseline (n = 31)		3 months (n = 33)
No intervention provided	5	16.1%	8	24.2%
Patient education (in groups or individually, sometimes including carers)	25	80.6%	17	51.5%
Home modifications (e.g. provision of rails)	17	54.8%	10	30.3%
Assistive technology (e.g. equipment, alarms)	14	45.2%	16	48.5%
Referral (to other disciplines, to community programmes e.g. Stepping On)	7	22.6%	10	30.3%
Exercise programme (group or individual)	5	16.1%	7	21.2%
Transfer training	1	3.2%	4	12.1%

Figure 3 provides an overview of the level of difficulty participants reported in different aspects of fall prevention practice. The greatest difficulty reported at baseline by 73% of participants was engaging with GPs, and the same was reported by 59% at 3 months after the workshop. Areas of fall prevention practice that were reported as involving less difficulty before or after the workshop were assessing and managing fall risk factors, and discussing fall prevention with older people. Reductions in difficulty regarding receiving referrals for fall prevention services were noted following the workshop. There were inconclusive results for participants in relation to sourcing evidence-based information about fall prevention, as more indicated they did not do this post workshop, and more participants reported difficulty. Less difficulty was reported in relation to liaising with and referring to other fall prevention providers, although more participants indicated that they did not do either of these at 3 months after the workshop.

Figure 3.

Difficulties experienced by participants in fall prevention activities at baseline (n = 31) and at 3 months post workshop (n = 33).

Perceived change in practice following the workshop

In the 3-month follow-up survey, 16 participants (48.4%) reported that they had changed their practice in some way since the workshop. Comments provided some insight into such changes: these included incorporating client education on fall prevention during usual care (n = 3, 18.8%), the use of new assessments or enhancing the assessment process to include fall prevention explicitly (n = 7, 43.8%), increased awareness of aspects of fall prevention such as polypharmacy and vision (n = 4, 25.0%), increased attention to lighting and lighting solutions (n = 4, 25.0%), referring to other service providers (n = 1, 6.3%), involving clients in finding solutions (n = 1, 6.3%), and developing a new fall prevention programme (n = 1, 6.3%). Three of the total survey respondents (9%) reported that they had not changed their practice as they felt they were already practising what was presented in the workshops, two (6.0%) reported that they were unable to or no longer worked in a service where they could implement home safety interventions, and six (18.1%) reported that they had not had the opportunity to work in fall prevention since the workshop.

Discussion

This study explored the current fall prevention practice and understanding of community occupational therapists working in primary care settings, and determined whether there were any changes elicited by participation in a professional development workshop. With 40 workshop participants from 33 private practices in the area, and high response rates for the surveys, we could be confident that the study had accessed the targeted population. Difficulties in regularly screening for fall risk, implementing evidence-based practice, collaborating with community services and confidence in implementing interventions were highlighted as key issues at baseline. Improvements were seen in the self-reported confidence and knowledge of participants, and in some elements of service delivery. However, challenges remain in assessing and managing fall risk factors and receiving referrals from other community-based service providers in order to be able to provide a high-quality primary care service for older people.

Low rates of fall risk screening were reported at baseline and follow-up. This may have a negative impact on the frequency at which health professionals can correctly identify or recognise older people at risk of falling. The Royal College of Physicians (2010) recommends that older people should be asked routinely about any falls by health professionals they see, regardless of the reason for the referral; this is particularly important in the community setting. Simply asking all older people about falls is an effective screening technique that can help identify individuals at risk, and can better target fall prevention assessment. The omission of fall screening in practice by study participants may not be due to participants being unaware of the importance of screening. It is possible that occupational therapists rely on the content of a referral to guide their practice. This is consistent with lower reported frequency of assessing for fall risk by participants, and the number of participants who reported using no assessment tools related to fall prevention practice. As the workshops were focused on home safety, available evidence-based home safety assessment tools were presented. Falls are a multifaceted issue, and assessing for fall risk can also identify specific areas of concern such as vision, cognition or muscle weakness (James et al., 2014). Occupational therapists need to use fall risk assessments in their practice to identify older people at risk of falls and to measure the outcomes of their intervention (Royal College of Occupational Therapists, 2015). However, there are no clear recommendations for which fall risk assessments should be used in community settings to predict falls, with support for performance-based assessments such as the Timed Up-and-Go test, Five Times Sit-to-Stand test, Berg Balance Test and assessments of gait speed (Lusardi et al., 2017; Power et al., 2014). Multifactorial interventions (interventions delivering more than one component) that also include an individual risk assessment have been shown to reduce rates of falls (Gillespie et al, 2012). By neglecting screening or assessing for fall risk, occupational therapists may be missing opportunities to provide tailored and individualised fall prevention interventions as part of their usual practice with older people.

Infrequent referrals for fall prevention to occupational therapists from GPs reflect concerns in the literature regarding the level of collaboration among primary health care providers (Grant et al., 2015; Mackenzie, 2009). GPs are often seen as gatekeepers for older people in the community to access AHP such as occupational therapists (Grant et al., 2015). As fall prevention interventions are typically provided by occupational therapists rather than GPs, it is important that there is good communication between GPs and occupational therapists. Better collaboration can facilitate greater quality of client care and ensure that at-risk older people are receiving evidence-based interventions. It may be unrealistic to expect a visible difference in outcomes for workshop participants in engaging with GPs and liaising with other service providers at 3 months after the workshop. However, the findings highlight an area of challenge that may benefit from further study or ongoing initiatives. Indeed, positive results have been seen from similar workshops promoting inter-professional collaboration (McKenzie et al., 2017). These workshops also included baseline and follow-up surveys to evaluate practice change, knowledge surveys, presentations and implementation plans for participants to engage in. However, the difference between our workshop and the workshop content of McKenzie et al. (2017) was individual coaching to develop individual protocols for enhancing fall prevention in participant workplaces. This workshop was only one of the ingredients of a much larger study aimed at embedding fall prevention effectively in primary care. It could be that, for occupational therapists and AHP more generally, a stronger emphasis on strategies for planning, managing and monitoring implementation is needed, as well as inter-professional workshops in order for referrals to work more seamlessly in practice.

The reported difficulty in sourcing evidence-based information reflects concerns in the literature about the application of current evidence among professionals (Child et al., 2012; Speechley, 2011). Difficulties in accessing evidence to guide practice suggest that these professionals may not currently be implementing best practice guidelines. Some occupational therapists may not have easy access to search engines and electronic libraries to view good-quality evidence, including systematic reviews. Although the workshops appeared to be successful in translating explicit understanding of workshop content according to the knowledge questionnaires, enhanced knowledge does not necessarily translate to practice change.

Half of the workshop participants indicated they had made some practice changes after the workshops, with a small number suggesting that change was unnecessary as they were already operating at the level recommended in the workshops. It was unclear how many participants could be expected to make some changes to their practice, and this may be a reasonable level of practice change to expect after only one workshop. Most participants appeared to change their service delivery in terms of problem-solving and actual fall hazards. Those that did make changes suggested a capacity to look critically and reflectively on their practice and seek improvements. This is consistent with a qualitative study (Clemson et al., 2014) that highlighted the complexity of implementing environmental fall prevention, the importance of engagement with clients, and the level of thoroughness and skill required. Some of the changes identified suggested that participants were being challenged to apply fall prevention principles to any older person they saw as part of usual practice, rather than only as part of a specific fall prevention programme. Such a primary prevention approach is essential in the primary care environment. Other changes related to providing a more comprehensive and high-quality service, either in the way that fall prevention assessment practices were enhanced, or in the range of interventions that were offered. These findings suggest that at least some of the participants were willing to modify their practice, and that the workshop was effective in eliciting these changes for them.

As in this study, other studies have identified that professional education can increase both knowledge and confidence among health professionals (McKenzie et al., 2017). However, the findings of this study highlight the continuing need for effective knowledge translation initiatives (Grimshaw et al., 2012), as this professional development workshop had limitations in eliciting change in professional practice for all the participants. One study on professional education programmes for health professionals in relation to fall prevention has indicated that they led to decreased fall rates (Tinetti et al., 2008). Future studies on the outcome of professional development fall prevention workshops should incorporate an evaluation of their effect on fall rates in the community.

Study limitations

Participation in the workshops was voluntary, with recruitment via snowballing and word of mouth. This may have produced a volunteer bias where occupational therapists with an existing commitment to fall prevention attended the workshops. Participants were only recruited from one area of Sydney; therefore, the sample size was small and results may not be generalisable to other primary health networks with varying sociodemographic characteristics or availability of service providers. The use of open-ended items for participants to report their use of assessments and interventions resulted in variations in depth of responses given, which may have led to some inaccuracies in coding these responses. All the data presented were self-reported, so there may be an element of social desirability bias (Mortel, 2008), where participants may want their practice to be seen in a positive light. More responses were acquired at follow-up than at baseline; this is attributed to repeat efforts to request workshop attendees to complete and return follow-up surveys, which was not done at baseline to the same extent. Finally, as all questionnaires and surveys were anonymous, it was not possible to link pre and post data for individual participants to measure self-reported change; therefore, only summarised results are presented, which may not be the same as actual individual change.

Conclusion

This study set out to identify the level of translation of falls prevention evidence into occupational therapy practice in the primary care setting. Occupational therapy practice in falls prevention was examined before and after an evidence-based workshop was provided, and issues were identified about how often occupational therapists screen older people for fall risk as part of their usual care, their use of evidence-based assessment tools and interventions, and their engagement with GPs and other service providers. Some positive practice changes were reported following the workshop; however, the potential for professional development workshops to be the primary means of promoting knowledge translation and practice change among community-based occupational therapists may be limited. Further studies to evaluate actual practice outcomes rather than relying on self-reported practice would enhance our understanding of effective fall prevention practice in the community.

Key findings

Participation in an evidence-based fall prevention workshop was associated with significant improvements in confidence and knowledge among occupational therapists working in primary care.

Self-reported practice changes were identified in half of the participants.

Gaps existed in fall prevention practice, including in screening practices, use of standardised assessment and use of evidence-based interventions.

What the study has added

This study has provided information on the fall prevention practice of occupational therapists working in one primary care setting in Australia. The study suggests that practice change is difficult to achieve through educational workshops alone. Aspects of practice that need to be further improved to reduce the risk of falls among older people have been identified.

Footnotes

Research ethics

Ethical approval was obtained from the University of Sydney Human Research Ethics Committee (#2014/316). Participants indicated their written informed consent to participate in the study through a check-box embedded in the on-line survey.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: National Health & Medical Research Council Partnership Grant ID 1072790.

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