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An educational video to promote multi-factorial approaches for fall and injury prevention in long-term… Dilley, Laura B; Gray, Samantha M; Zecevic, Aleksandra; Gaspard, Gina; Symes, Bobbi; Feldman, Fabio; Scott, Vicky; Woolrych, Ryan; Sixsmith, Andrew; McKay, Heather; Robinovitch, Steve; Sims-Gould, Joanie May 20, 2014

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RESEARCH ARTICLE Open AccessAn educational video to promote multi-factorialapproaches for fall and injury prevention inlong-term care facilitiesLaura B Dilley1,2, Samantha M Gray3, Aleksandra Zecevic4, Gina Gaspard5, Bobbi Symes3, Fabio Feldman5,Vicky Scott6, Ryan Woolrych7, Andrew Sixsmith7, Heather McKay1,8, Steve Robinovitch3 and Joanie Sims-Gould1,8*AbstractBackground: Older adults living in long term care (LTC) settings are vulnerable to fall-related injuries. There is aneed to develop and implement evidence-based approaches to address fall injury prevention in LTC. Knowledgetranslation (KT) interventions to support the uptake of evidence-based approaches to fall injury prevention in LTCneed to be responsive to the learning needs of LTC staff and use mediums, such as videos, that are accessible andeasy-to-use. This article describes the development of two unique educational videos to promote fall injury preventionin long-term care (LTC) settings. These videos are unique from other fall prevention videos in that they include videofootage of real life falls captured in the LTC setting.Methods: Two educational videos were developed (2012–2013) to support the uptake of findings from a study exploringthe causes of falls based on video footage captured in LTC facilities. The videos were developed by: (1) conductinglearning needs assessment in LTC settings via six focus groups (2) liaising with LTC settings to identify learningpriorities through unstructured conversations; and (3) aligning the content with principles of adult learning theory.Results: The videos included footage of falls, interviews with older adults and fall injury prevention experts. The videospresent evidence-based fall injury prevention recommendations aligned to the needs of LTC staff and: (1) highlightrecommendations deemed by LTC staff as most urgent (learner-centered learning); (2) highlight negative impactsof falls on older adults (encourage meaning-making); and, (3) prompt LTC staff to reflect on fall injury preventionpractices (encourage critical reflection).Conclusions: Educational videos are an important tool available to researchers seeking to translate evidence-basedrecommendations into LTC settings. Additional research is needed to determine their impact on practice.BackgroundOlder adults who live in long term care (LTC) facilities arehighly vulnerable to falls and fall-related injuries [1,2]. Mostolder adults living in LTC (60%) will sustain at least one fallper annum [3]. Given that falls are the leading cause ofinjury-related deaths and hospitalizations among olderadults [2,4], preventing falls and fall-related injuries amongthis population is an urgent health priority. Recent researchhas recommended that falls injury prevention in LTCsettings involve multifactorial approaches [5], which requireconducting comprehensive assessments of the person andenvironment, establishing what factors create risk, andimplementing a set of interventions that address thosefactors [6]. For example, removing environmental hazards,implementing an exercise programme and overseeingchanges to medication regimes would together constitute amultifactorial fall prevention strategy [6]. Continuing edu-cation for LTC staff is a critical piece of fall preventionstrategies in LTC settings, as it ensures that staff has accessto information regarding best practices [7-9].The Technology for Injury Prevention in Seniors (TIPS)program is a multi-year research program funded by theCanadian Institutes of Health Research (CIHR) that seeks toidentify best practices in fall prevention and translate these* Correspondence: simsg@mail.ubc.ca1Centre for Hip Health and Mobility, 7/F, 2635 Laurel St, Robert H.N. HoResearch Centre, Vancouver, BC V5Z 1M9, Canada8Department of Family Practice, Faculty of Medicine, University of BritishColumbia, Vancouver, British Columbia, CanadaFull list of author information is available at the end of the article© 2014 Dilley et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the CreativeCommons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, andreproduction in any medium, provided the original work is properly credited.Dilley et al. BMC Medical Education 2014, 14:102http://www.biomedcentral.com/1472-6920/14/102into practical and sustainable strategies for LTC settings.TIPS used innovative technologies to determine the causesand circumstances of falls among older adults, including:1.)Networks of digital video cameras and wearablesensors to record falls and fall mechanisms and2.)Hip protectors and compliant flooring to reducethe risk for fall-related injuries.As part of the TIPS study, digital video cameras wereinstalled in common areas (dining rooms, lounges, andhallways) of two LTC facilities in British Columbia,Canada. Cameras recorded resident activities and anyadverse events, such as falls. This footage provided uniqueevidence of the causes and mechanisms of falls withinolder adults’ everyday context [1]. Incorrect weight shift-ing (i.e., shifting of the body's center-of-gravity outside thebase of support provided by the feet) was identified as themost common cause of falls, and these most commonlyoccurred when individuals were walking, sitting down, orstanding [1].Given the significant potential for TIPS to inform multi-factorial fall prevention strategies, and requests from LTCstaff to view the video captured falls in efforts to improvetheir practices around fall and injury prevention, theresearch team (SKIPS: “Support Knowledge and InjuryPrevention in Seniors”) was formed. The goal of SKIPS(also funded by CIHR) was to promote the uptake ofTIPS research findings among staff in LTC settings, andincluded TIPS research team members (FF, JSG, BS,HM & SNR), geriatrics researchers (AS, RW & AZ) andnurses and administrative staff with experience in LTCsettings (GG & VS). Given the unique opportunitiesprovided by the video footage of falls, the project teamdecided to develop two educational videos for use indegree and diploma programs for LTC staff (e.g., nurses,care aides, etc.) and as part of continuing education inLTC settings. The decision to make videos was basedon the availability of the fall capture videos and re-quests from LTC to develop fall and injury preventioneducational materials that were easy to understand,easy to access and could be delivered on a coffee break(around 15–20 minutes).The two videos were developed in conjunction withthe SKIPS team and LTC staff. The videos integrate fallcapture video footage and interviews with older adults,LTC staff, and fall prevention researchers and provide apractical, easy-to-understand approach to implementfall prevention recommendations in LTC settings. Theseeducational videos draw upon principles of adult learningtheory [8,10,11]. The videos provide educators with aneasy to use tool that can be used in academic settings,LTC settings and as part of continuing and online educa-tion. The videos (available at: http://www.youtube.com/sfuTIPS) and accompanying curriculum for classroom andcontinuing education activities (available at: http://www.sfu.ca/tips), are designed to improve fall injury preventionin LTC settings through increased understanding of thecauses of falls and how falls might be prevented. They alsoprovide a seldom seen look at what actual falls looklike. Most falls go unwitnessed so these educational vid-eos provide a rare opportunity to stimulate discussionabout real fall instances. Based on these educationalvideos, the objectives of this paper are to: 1) outline theunique aspects of these videos and; 2) provide an over-view of the video development process to assist nurseeducators (and others) who may wish to conduct similarprojects, in future.MethodsDevelopment process: from pre-production todisseminationIn 2012, the SKIPS team embarked on a one-year projectto develop two educational videos, “Everybody Falls Some-time: An Introduction to the Prevention of Falls and Injuriesin Long-Term Care” and “Evidence from Real-Life Falls:How to Manage Risk and Prevent Injuries in Long-TermCare”, to support the implementation of evidence-basedfall and fall related injury prevention training in LTCsettings. Educational videos were identified as the idealstrategy given that video was a medium through whichthe previously acquired fall capture videos [1] could beshowcased. In addition, visual media is critical in promotingengagement, critical awareness and deep learning amonglearners by modelling experiences directly relevant to theirlives [12,13]. It was also determined that educational videoswould be helpful because they could be easily accessedby nurse educators and students at any time of day ofany location [12], and supported opportunities for continu-ous reinforcement, distance learning and reflection andengagement beyond the workplace. We also had feedbackfrom LTC staff that had seen some of the video capturedfalls through presentations by our research team and hadrequested the opportunity to show these videos to theircolleagues (and have discussion about them).Interdisciplinary teamAn experienced adult educator with a background in visualarts was hired as the Project Coordinator (LBD) to developthe videos in collaboration with the TIPS study team. Inaddition, the Project Coordinator regularly consulted withhealthcare professionals working in LTC settings, includingclinical nurse specialists and nurse educators, to enhancethe relevance of the video and supporting curriculum forLTC staff. The Project Coordinator also had access to tran-scripts from six focus groups with the LTC staff on theirpractices and learning needs with respect to fall and injuryprevention. This interdisciplinary approach was rooted inDilley et al. BMC Medical Education 2014, 14:102 Page 2 of 6http://www.biomedcentral.com/1472-6920/14/102the acknowledgement that, due to the complexities offall injury prevention in LTC settings and the need fordiverse perspectives to develop comprehensive fall preven-tion strategies. This approach recognized that fall injuryprevention is beyond the scope of any single discipline,and that engaging diverse viewpoints allows for the deve-lopment of a more holistic approach to learning [14,15].Learning needs assessmentThe Project Coordinator conducted a learning needsassessment for fall injury prevention in LTC settings bydrawing on findings from the focus groups, conversationswith LTC staff and residents, peer-reviewed articles, andevidenced-based best practice guidelines available online.The project team determined that LTC staff needed fur-ther education regarding: (i) how to identify extrinsicand intrinsic risk factors for falls; (ii) how to implementmultifactorial risk reduction strategies for fall injuryprevention; and, (iii) ethical dilemmas relating to qualityof life and autonomy in the context of fall injury preven-tion. These learning needs informed the development ofthe video so as to enhance its relevance to LTC staff andconsider potential resource limitations in LTC settings.To respond to these learning needs, SKIPS was guidedby a conceptual approach that was designed to encouragepractice reflection. This approach suggests that learnersconstruct knowledge through a process of meaning-makingthat involves the hearing, telling and recognizing of stories[11,16]. Thus, in the introductory video, “Everybody FallsSometime” older adults and long-term care staff sharedstories of their experiences with falls and fall injury pre-vention. Learners are prompted to think about their ownexperiences in relation to the video [17]. In this regard,the learner makes sense of what they see and hear in thevideo by relating it to what they already know. Oncelearners engage in this process (referred to as ‘meaningmaking’), they are able to translate this new knowledgeinto their own stories. Through this process, the contentof the story becomes more immediate, relevant and per-sonal for the learner, which creates a deeper connectionwith the material [16,18]. In this instance, because thefirst video captures care aides and older residents ofLTC, this process of meaning making is likely to be morepoignant for these groups. The second video, “Evidencefrom Real-Life Falls”, emphasizes evidence-based recom-mendations for fall and injury prevention, and seeks tohighlight steps that the motivated learner can take tominimize falls in LTC settings.Development process-meetingsThe project team met four times over the course of theproject. During an initial phone meeting, the project teamfinalized a project timeline and discussed the video’sobjectives. Next, the Project Coordinator developed avideo treatment, which outlined the video shoot location(i.e., one of the partnering LTC facilities), potential partici-pants, approach to the video, and other technical aspectsof creating the video. These dimensions of the final prod-uct were informed by initial project meetings, site visits tothe partnering LTC facility, and lessons learned during thelearning needs assessment.The second meeting (in-person) involved ‘pitching’ thevideo treatment to the project team. Project team mem-bers were provided a detailed script that outlined thestructure and content of the video in advance of the meet-ing. The script was revised during the meeting. Projectteam members viewed TIPS fall capture videos that werelinked to key research recommendations and discussedhow these might fit within the new video. The projectteam determined that two nurse educators (GG & VS)and two biomechanical engineers (SNR & FF) wouldappear in the video, and each would speak to a fall cap-ture video and provide accompanying evidence-basedpractice recommendations.At the next meeting (in-person) the project teamreviewed a rough cut of the video. A feedback form wasused to make recommendations that would guide theediting process. Following this meeting, a rigorous edit-ing session was conducted to complete the video. At thefinal meeting (by phone), the team discussed the videodissemination strategy. As a part of this disseminationstrategy, the Project Coordinator worked collaborativelywith nurse educators on the project team (VS & GG)and clinical nurse specialists and nurse educators in bothof the partnering LTC settings to develop lesson plans toaccompany the videos. These lesson plans elaboratedupon the videos by linking the narrative content to spe-cific evidence-based recommendations identified in theTIPS project. Lesson plans were designed for LTC andacademic settings. At various stages of the project, theproject team consulted with nurse educators to ensurecontent and tone was consistent with the needs of LTCstaff and relevant for preparing students enrolled inacademic programs to provide care and support to olderadults in LTC settings.ResultsThe educational videosThe final deliverables were one 7 minute video and one12 minute video, designed to be watched independentlyor together. “Everybody Falls Sometime” weaves togetherthe stories of older adults and LTC staff in relation tofalls and fall injury prevention. It seeks to prompt reflec-tion on fall injury prevention practices among learnersby validating their experiences and highlighting thesocial, emotional and physical impacts of falls. Evidencefrom Real-Life Falls, is more didactic and presents fallcapture videos and interviews with fall injury preventionDilley et al. BMC Medical Education 2014, 14:102 Page 3 of 6http://www.biomedcentral.com/1472-6920/14/102experts who link falls video footage to evidence-basedpractice recommendations. “Everybody Falls Sometime”may be particularly valuable to nurse educators who chooseto emphasize the affective domain of learning (i.e., how welearn through feelings and emotions). Evidence from Real-Life Falls is tailored to the cognitive domain of learning(i.e., how learn based on facts and concepts). These videosare described below.“Everybody falls sometime”: an introduction to theprevention of falls and injuries in long-term careTo develop this video we adopted widely accepted tenetsof adult learning theory; for example, the need to involveadults in the planning and evaluation of their instruction[10]. Therefore, LTC staff were invited to participate inthe production of the video through the telling of their‘fall injury prevention’ stories. Specifically, the ProjectCoordinator and a research assistant interviewed threeLTC staff (two care aides and one licensed practicalnurse) who focused on their experiences with fall andinjury prevention in LTC settings. The interviews wereconducted over three days in one of the partnering long-term care facilities. Semi-structured interviews were alsoconducted with three older adults who lived in this facilityand who had experienced a fall. These individuals wereasked questions regarding: 1.) how aging has impactedtheir mobility; 2.) what factors they believed contributedto their video captured fall and any subsequent falls; and,3.) How they have been impacted by falls.Participant narratives were used to tell the stories ofLTC staff and older adults as experienced by staff andresidents. The Project Coordinator in liaison with thelarger team selected narratives to represent key themesthat emerged during interviews with participants (i.e.,circumstances under which unexpected shifts in weightoccurred and environmental factors contributing tofalls). Learning in adulthood is based on lived experience[11]. Thus, the candid nature of the interviews set withina LTC setting served as a powerful tool that staff identifiedwith. Knowles and colleagues [10] suggest that adults aremost interested in learning about subjects that haveimmediate relevance to their work and personal lives. Thevideo sought to build upon this interest by emphasizingthe lived experiences of LTC staff and older adults. Thismakes this video unique from other fall and injury preven-tion videos in that it is both for LTC staff and older adultsand created and narrated by LTC staff and older adults.Evidence from real-life falls: How to manage risk andprevent injuriesThe second video took a more traditional approach toinstruction. Content was comprised of fall preventionexperts who discuss four fall-related scenarios. Each casestudy begins with an introduction to address key issuesrelated to cause and prevention of falls. Next, the videoshowcases a vivid, fall captured video that represents acommon combination of cause and activity leading to afall (e.g., tripping during walking, incorrect transferringduring sitting down or rising, hit/bump, loss of conscious-ness). The onscreen case study discussion focused on:(1) what caused this fall; (2) how could the fall havebeen prevented; and, (3) what could be done to preventinjury in the event of such falls.Researcher interviews in combination with fall capturevideos create a synergy of auditory and visual learningstyles. Dual-channel processing is more effective thansingle channel learning and learning is improved wheninstruction includes both visual and verbal information[19]. The inclusion of the real life fall video capturedsegments makes this video unique from other fall andinjury prevention. This video gives the viewer a look atwhat is seldom seen, an actual fall in progress.Implementation of dissemination strategyThe completed videos were disseminated by the ProjectTeam using a multi-dimensional strategy. This strategyengaged local community partners and included web-baseddistribution of the videos. In the local context, copies of thevideo and supporting curriculum were distributed to nurseeducators in LTC settings across two health regions. Videoswere screened at a local Geriatrics Services conferenceattended by more than 300 health care professionalsand were featured at a Nurse Educator meeting hostedby the local health authority, attended by 18 clinicalnurse educators and 4 clinical nurse specialists.The project team undertook several activities to expandthe reach of the video beyond the local area. First, videoswere posted to YouTube along with keywords to attractweb traffic. The project team also disseminated infor-mation regarding the videos using nursing and geriatricslistservs, newsletters, and social media. Further dissemin-ation plans involve laying videos at LTC staff meetings,presentations at conferences (e.g. National Fall PreventionConference, Toronto, May 2014).DiscussionThe videos offer nurse educators a novel compliment oralternative to a traditional lecture format. The portabilityof the video provides learners and educators the oppor-tunity to view the videos in a variety of settings, (i.e. in thework setting, classroom, at home and on their mobiledevices). Educational media that is accessible, convenient,and learner-centered may improve the teaching and learn-ing of content [12]. The videos are designed to enhancethe learners understanding of mechanisms linked tofalls in older adults – an essential element to improveprevention strategies. The use of best practices andevidence-based content, as promoted in the videos, is aDilley et al. BMC Medical Education 2014, 14:102 Page 4 of 6http://www.biomedcentral.com/1472-6920/14/102major priority with LTC and a requirement for accredit-ation. Our training tools are designed to respond to theneeds of LTC care staff and administrators, healthauthorities, and ministries of health. We believe thatvideo is a worthwhile and effective tool when thosewho will be on the receiving end of the education areinvolved in the production and narration of the videos.We also believe that the videos are but one mechanismto disseminate the findings from the larger TIPS programof research. The videos complement peer reviewed publi-cations, presentations and lay research summaries andensure that TIPS findings are accessible to a range ofaudiences.These visual, teaching and learning tools will be usedby LTC staff and integrated into training programs fornew staff to promote understanding of mechanisms thatcause falls and to improve fall risk assessment and pre-vention strategies. Nurse Educators might also use thesevisual methods to highlight other related topics in thecurriculum or to tailor learning to specific issues thatarise in work settings. Fall capture videos provide learnerswith the rare opportunity to observe react to and criticallyexamine a real-life fall without the urgency that accom-panies bearing witness to one. Lessons learned can beused to inform and perhaps enhance practice, in future.LimitationsThis project encountered several challenges, and hadseveral limitations, that should be considered. First, therelatively short time-frame for this project (one-year)limited the number and depth of consultations with LTCstaff during the learning needs assessment. While thepreviously conducted focus groups had generated in-sights into the learning needs of LTC staff, they werenot specifically focused on educational videos. Second,older adults who participated in the videos experiencedmultiple health challenges. These limited their ability toparticipate in video shoot over sustained periods oftime. Finally, these videos were designed with a specificuse in mind – to effect positive change in fall and injuryprevention in LTC settings only, and may not be relevantto other settings.ConclusionThe videos’ content weaves together the experiences ofLTC staff and older adults and expert commentary byresearchers to engage the learner. This approach, wherethe viewer is able to reflect on their own experiences inrelation to what is happening in the video can contributeto improved practice [20]. The videos are less about“showing” LTC what to do but rather a mechanism toget them to think about what they are doing and howthey might do it better (or differently) to help preventfall and injuries. This approach, combined with expertcommentary punctuates this ‘experiential or reflectivelearning’ with evidence-based fall injury prevention bestpractices. In conclusion, we believe that these videoshave the potential to be more impactful than other falland injury prevention videos for three reasons: 1) Weinvolved end-users in the development of the videosfrom the inception stages; 2) Our approach was toguide leaners to think about their practice in relation towhat they are seeing (as opposed to simply telling themwhat to do); and 3) we included very powerful andunique images of video footage of real life falls. Ournext step is to assess whether these videos are effectivelearning tools in influencing fall and injury preventionpractices amongst LTC staff.Competing interestsThe authors declare that they have no competing interests.Authors’ contributionsAll authors contributed to the conceptualization of this study and developmentof the videos. LBD wrote the first draft of the manuscript. All authors contributedto the critical revision of the manuscript and approved the final version.AcknowledgementsWe are indebted to the staff and residents of Delta View Life EnrichmentCentre and Habilitation Centre, and New Vista Society Care Home for theircommitment and valued partnership in this study. An enthusiastic thank youto Farzine MacRae for his assistance with video production and to the staffat the Centre for Hip Health & Mobility for their research and administrativesupport. We are grateful for the Canadian Institutes for Health Research grantthat supported this work (TIR-103945 and AMG-100487). Stephen N. Robinovitchis supported by a Canada Research Chair award (in Injury Prevention and MobilityBiomechanics).Author details1Centre for Hip Health and Mobility, 7/F, 2635 Laurel St, Robert H.N. HoResearch Centre, Vancouver, BC V5Z 1M9, Canada. 2Faculty of Education,Simon Fraser University, Burnaby, British Columba, Canada. 3Injury Preventionand Mobility Laboratory, Department of Biomedical Physiology and Kinesiologyand School of Engineering Science, Simon Fraser University, Burnaby, BC,Canada. 4Faculty of Health Sciences, School of Health Studies Arthur and SoniaLabatt Health Sciences, Western University, London, ON, Canada. 5Fraser HealthAuthority, Surrey, BC, Canada. 6British Columbia Injury Research & PreventionUnit and Ministry of Health, Office for Injury Prevention, Victoria, BC, Canada.7Gerontology Research Centre, Simon Fraser University, Vancouver, Canada.8Department of Family Practice, Faculty of Medicine, University of BritishColumbia, Vancouver, British Columbia, Canada.Received: 21 August 2013 Accepted: 6 May 2014Published: 20 May 2014References1. 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Schon AD: Reflective practioner: How professionals think in action. New York:Basic Books; 2000.doi:10.1186/1472-6920-14-102Cite this article as: Dilley et al.: An educational video to promotemulti-factorial approaches for fall and injury prevention in long-termcare facilities. BMC Medical Education 2014 14:102.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript at www.biomedcentral.com/submitDilley et al. BMC Medical Education 2014, 14:102 Page 6 of 6http://www.biomedcentral.com/1472-6920/14/102

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