Public Health Nursing Vol. 18 No. 3, pp. 1691770737-1209/01/$15.00 Blackwell Science, Inc.Home-Screen: A Short Scale toMeasure Fall Risk in the HomeMaree Johnson, R.N., Ph.D.,Anne Cusick, B.App.Sci., Ph.D., andSungwon Chang, B.Sc., M.Stats.as a monitoring tool for community nurses working with olderAbstract Community nurses are often the health professionalspeople, is recommended.with whom older Australians living at home have most contact.Key words: community nursing, occupational therapy, falls.The home environment has been identified to have a number ofhazards associated with falls in older people. The Home-screenscalewas specificallydesigned asa nurse-administeredinstru-ment toidentifyenvironmental andbehavioral risksthat alertnurses to the need for action to reduce fall risks in the home. A INTRODUCTION14-item scale was administered to 1,165 older people receivingOneinthreeolderpeoplelivinginthecommunitywillcommunitynursingservices. Psychometricinvestigationcon-experience a fall this year (El-Faizy & Reinsch, 1994). Anfirmed a 10-item scale with construct validity and internal consis-important area of risk for falls by older people is the home tency ( 0.86, n 989), explaining 60% of the construct ofhome safety (safe home environment and safe home behaviors). environmentandthewayinwhicholderpeopleusetheIn addition, differences in mean scores were found in clients able home(Connell &Wolf, 1997; Josephson, Fabacher, &and unable to transfer independently (t 4.5 [df 323.1] p 0.40)toileting facili-total scores for the total Home-screen scale and total Home-ties and items are easy to reach and use at night (fromsafe subscale and total Home-behavior subscale were cal-Home-safe), and person uses stable, clean toileting facili-culated. The investigators aimed to produce an instrumentties or aids (from Home-behavior). After deleting thesethat would prompt nurses to act on home environment ortwocross-loadingitems, furtheranalysiswassuggestivehome behavior hazards either by seeking assistance fromof a configuration of 10items within two factors. Whenoccupational therapists or by implementing targeted nurs-principal components factor analysis was programmed toing interventions where such specialist services were notproduce2factorstocorrespondtothepredetermined2available. To provide a prompt for action by nurses usingsubscalesoftheinstrument(homesafeandbehavior),itthe scale, a score on the total home-screen scale was soughtaccounted for 60%of the variance (see Table 2) and demon-that wouldindicatetheneedfor intervention. Thiswasstrated a two factor solution on scree plot. Examination ofconsidered to be a critical point on the scale that reflectedthe factor matrix showed one item loaded more appropri-a threshold of risk.atelyontheHome-behaviorsubscalethantheoriginallyByusingthesetotalscoresatthe25thpercentile, thedesigned Home-safe subscale: shoes usually worn atscore for the Home-screen scale was 71. This means thathome fit well and have good traction on heels and solesonly 25% of this entire sample (247/989) had a score of(home-safe). ThebestfactorsolutionappearsinTable271orless, representingpoorhomesafetyandbehavior.andincludestherelocationof theaboveitem. Table2Similarly, the 25th percentile score was 36 for the Home-highlights the high factor loadings (0.650.81) for all items.safe subscale and 33 for the Home-behavior subscale. Per-centiles, rather than a derived score, have been chosen asDifferences in Known Groupsthemeanscoresfor theitems, andthereforescalesaregenerally high. It is also notable that 50% or more of this Another approach to confirming the underlying construct isto examine differences in the instrument with groups that sample had a total Home-screen score of 84.Further confirmation ofthe utility of thecritical point would be perceived as likely to differ on the scale. In thiscase, the itemrelating to transfer fromthe Community Nurs- of 71wassought byexploringtheassociationbetween174 Public Health Nursing Volume 18 Number 3 May/June 2001TABLE 2. Characteristics of Items in Home-Screen Best Solution: Principal Component Analysis Using Varimax Rotation Methodwith Kaiser Normalization for Two Factors Using Ten ItemsItem Mean SD ITC Factor 1 Factor 2Home-safeRooms/halls are free of clutter 7.89 2.59 0.67 0.78 0.16Rooms/halls have good daylight 8.10 2.39 0.70 0.84 0.11Rooms/halls have good night lighting 8.34 2.27 0.72 0.82 0.20Floor coverings in home are even, firm, and nonslip 8.36 2.28 0.63 0.76 0.17Bathing/showering facilities and items are easy to access and use 8.36 2.38 0.50 0.60 0.34Home-behaviorPerson moves carefully through the house 8.04 2.58 0.67 0.20 0.81Person wears footwear correctly 7.78 2.99 0.67 0.23 0.75Person takes care when doing things at home 7.86 2.67 0.65 0.14 0.81Person puts lights on at night if getting up 8.19 2.99 0.44 0.01 0.65Shoes usually worn at home fit well and have good traction on heels and soles 7.62 3.00 0.58 0.31 0.65ITC Item-total correlation.Home-safe subscale: Cronbachs alpha 0.84 (5 items).Home-behavior subscale: Cronbachs alpha 0.81 (5 items).Overall cumulative variance explained for all items and Home-screen scale was 60% with a Cronbachs alpha of 0.86. Scree plotdemonstrates 2 components with an eigenvalue of greater than 1.veterans with low (scores of 71 or less on the Home-screen DISCUSSIONscale) and high (scores greater than 71) home safety andHealthpromotioninolder peopleremainsanimportantbehavior, and veterans experiencing falls. An itemreferringand developing role for public health nurses (Davis, 1994).to falling behavior: does the beneficiary experience fall-Falls preventionandtools that assess thepotential foring behavior (response never [1], rarely [2], occasionallyfalls, shouldbeincludedinanycomprehensivenursing[3], frequently [4]) was used to form two groups: Groupassessment of community-living older people (Lange,1, scores of 3 or less and Group 2, scores of 4. Chi-square1996; Moss, 1992; Williams & Nolan, 1993). This studyanalysis demonstrated that veterans with poor home safetysought to develop and test a short screening tool that couldand behavior (scores of 71 or less on Home-screen) alsobe used by community nurses to assess home environmentsexperienced frequent falls (2 15.4, df 1, p < 0.001,and home behavior that may constitute a risk for falls. Thisn 726). Alsoit is notablethat 74.2%(539/726) ofresearch fills a gap in the nursing literature (Willis, 1998).veterans had a score of more than 71.TheHome-screenwasdesignedtoprompt nursestoactIt wasalsopossibletousethiscritical point toformon these risks through referral to specialist services suchgroups of high and low Home-screen scorers and compareas occupational therapy and targeted nursing interventionsthese with the proportion of veterans perceived by commu-to reduce the hazard. These interventions could replicatenity nurses to require support services used or plannedor extend nursing falls prevention programs already pre-home modification. Chi-square analysis demonstratedsentedintheliterature(Mah, 1996; Ploeget al., 1994;that a slightly higher proportion of veterans with poor homeSchlapman, 1990; Schoenfeld & Van Why, 1997; Tideik-safety and behavior (scores of 71 or less on Home-screen)saar, 1989; Weber, Kehoe, Bakoss, Kiley, &Dzigiel, 1996).were also identified as needing or having home modifica-We acknowledge that more comprehensive home hazardstion service, although this was not significant at the 0.05assessment tools exist, in particular the WeHSA (Clemson,level (2 2.0, df 1, p 0.097, n 989). Further1997), but these tools require specialist professional skillanalyses were undertaken using a higher critical point of 74and considerable time to complete.to split the groups. These analyses resulted in a statisticallyThis sample of older community-living Australians rep-significant difference (24.15, df 1, p 0.047, n resent a group of older men and women with high function-989), with higher proportions of veterans with high Home-ality and mainly fair or poor health; a group of older peoplescreen scores (scores of greater than 74) being perceived assusceptible to falls. not requiringhome modificationservices andhigher propor-The primary aim of this study was to examine the quality tions of veterans with low Home-screen scores (scores ofoftheinstrument throughpsychometricinvestigationof 74 or less) being perceived as requiring home modificationservices. the validity and reliability of Home-screen. The final solu-Johnson et al.: Home-Screen Scale 175tion10 items (5 for Home-safe, 5 for Home-behavior) cation services were required or not required. Theseanalyses were not statistically significant at the 0.05 level explained60%oftheconceptofhomesafetyandhomesafe behavior, confirming adequate construct validity (Hair, using a score of 71, but were significant when a score of74 was used as the splitting point for low and high scorers. Anderson, Tatham, & Black, 1992). The results revealedthat the14-itemscalewasimprovediffouritemswere Fromthese preliminary analyses it would seem that thereis support for the statement that a score of 74 or less should deleted, andif oneitem(relatingtoshoes) wasmovedfrom the Home-safe subscale to the Home-behavior sub- be an indicator to the nurse of a need to seek specializedservices, if available, or to immediately initiate an educa- scale. For the latter, some modification to the itemis recom-mended to allow it to be consistent with the Home-behavior tion program. This threshold score, or critical point, is quitehigh. This is not surprisinggiventhat thesamplelive scale,thatis:Personwearsshoesathomethatfitwelland have good traction on heels and soles. independently in the community and have high functional-ity.Consequently,thescaledoeshaveahighmeanitem Construct validity of the instrument was further exploredthrough examination of differences in known groups using scoreandthereforehighoverall score, whichresultsinahighthresholdvalue. Clinically, thishighscoring(or independenceanddependenceontransferasagroupingvariable. This item was selected as ability to transfer has threshold value) is important to note as community nurses,who can be faced with a wide variety of living conditions been previously identified as a risk factor for falls(McLean & Lord, 1996; Ray et al., 1997), and may also of their clients, need to recognize that a home environmentthat is superficially comfortable and acceptable, may hold be considered an indicator of mobility (an important issuein falls prevention). Veterans who could transfer indepen- safety risks that require attention to detail beyond mattersof cleanliness and comfort. dently had higher mean scores than those who could notand this difference was statistically significant, demonstra- Ashort screeningtool that assesseshomesafetyandhome safe behavior in community-living older people has ting that the Home-screen could appropriately differentiatebetween the groups. beendevelopedandfoundtobebothvalidandreliable.Previously, the lack of appropriate community nursing tools Internal consistency (a form of reliability) was also ex-plored, and confirmed with alpha coefficients ranging from inthearea wasaproblem,and mayhavecontributedtothe high number of nurses who did not use an instrument 0.81 (Home-behavior), and 0.84 (Home-safe), to 0.86 forHome-screentotal scalewell withinacceptablelevels of any kind to assess this fall risk (Willis, 1998). The Home-screenscale couldeasilybe incorporatedintheinitial (Nunnally, 1978).TheHome-screenwasdesignedtoact asascreening assessment ofaclient asit isshort, requiresnospecialtraining, and relies upon knowledge gained through routine instrument to prompt nurses to reduce falls through atten-tiontowell documentedextrinsicriskfactorsof home practice with the client in the home. This instrument couldalsobeusedasamonitoringtool toassesschangesin environment and home behavior. Consequently, it was im-portant to identify a critical point that reflected a threshold behavior and the environment following education or homemodification programs. of riskinrelationtotheseareas. Thresholds of riskhave been identified to be an important dimension of falls Further research is required in a number of areas. First,thereisaneedtoexplorepredictivevaliditytestingto prevention (Wolter & Studenski, 1996). This is importantbecause the multifactorial nature of falls means that inter- confirm that this instrument is predictive of injury and fallsinolderpeopleortheexaminationofspecifichighrisk vention that targets any one area or factor may have limitedeffect if it does not lower the overall threshold of fall risk subgroups. Second, the development of an administrationmanual that would include the provision of structured defi- (Wolter & Studenski, 1996).An attempt to derive such a point was made based on nitions for key terms such as clutter to assist raters andensureincreasedconsistencyis required. Third, further thescorerepresentingthe25thpercentile(71). Findingsfrom the analyses of veterans Home-screen scores, using investigation is required into the nature of the items them-selves, in particular, the interrater reliability of the overall ascoreof71orless(anolderpersonatrisk)andthosewith a score of more than 71, found an association between scale, subscale, and items. Ultimately, the clinical successof assessments such as the Home-screen is the ability of the groups of low and high scorers and frequent and infre-quent falling behavior. Here it was apparent that frequent the nurse to use the information to successfully encouragechangebytheolderpersonstomaketheirhomessafer. fallerscouldbedistinguishedfromothersinthesampleon the basis of score (71 or less) on the Home-screen. This More research is required to understand why such changeis difficult to achieve (Clemson, Cusick et al., 1999; isnot surprising, giventherolethat homeenvironmentand behavior have in fall risk (Connell & Wolfe, 1997). Schoenfelder & Van Why, 1997).Public health nurses have an important role to play in Similar analyses were undertaken using the same group-ings and community nurses perceptions that home modifi- falls prevention and the use of the Home-screen scale pro-176 Public Health Nursing Volume 18 Number 3 May/June 2001Cooper, B. A., Cohen, U., & Hasselkus, B. R. (1991). Barrier- vides these nurses with a valuable tool to heighten aware-free design: A review and critique of the occupational therapyness, frameinterventionprograms, seekspecializedhelpperspective. Canadian Journal of Occupational Therapy, 45,where available, and confirm successful actions when en-344350.acted. Makingthehomesafefor older peoplenot onlyCumming, R. G., Thomas, M., Szonyi, G., & Salkeld, G. (1998).reducesolderpeoplesmorbidityandmortality, but alsoRandomised trial of home hazard reduction for prevention ofadds to their quality of life by reducing their fear of falling.falls. Paper presented at the Australian Public Health Confer-ence, Hobart, Tasmania.Davis, J. A. (1994). Older Australians: A positive view of ageing.REFERENCESSydney: W.B. Saunders/Bailliere Tindall.Australian Council of Community Nursing Services, Inc. (1994).Donald, I. P., & Bulpitt, C. J. (1999). The prognosis of falls inCommunity nursing minimum data set Australia: Version 1.0.elderly people living at home. Age and Ageing, 28, 121125.Report of pilot implementation project Melbourne: AustralianEl-Faizy, M., &Reinsch, S. (1994). HomesafetyinterventionCouncil of Community Nursing Services Inc.for the prevention of falls. Physical and Occupational TherapyAustralian Council of Community Nursing Services, Inc. (1997).in Geriatrics, 12(3), 3349.Community nursing minimum data set Australia: Version 2.0.Fleming, B. E., & Pendergast, D. R. (1993). Physical condition,Data dictionary and guidelines. Melbourne: Australian Coun-activity pattern, and environment as factors in falls by adultcil of Community Nursing Services Inc.carefacilityresidents. Archives of Physical Medicine, 74,Australian Institute of Health and Welfare (AIHW) and Common-627630.wealthDepartment ofHealthandFamily Services(DHFS).Fortin, J. D., Yeaw, E. M. J., Campbell, S., & Jameson, S. (1998).(1997). Firstreport onnational healthpriorityareas1996An analysis of risk assessment tools for falls in the elderly.(AIHW Cat. no. PHE1). Canberra: AIHW and DHFS.Home Healthcare Nurse, 16(9), 624629.Bye, R., Bruce, M., McCallum, J., Jackson, D., Owen, A., &Frampton, G., Cumming, R., & Thomas, M. (1999). Home visitsKemp, L. (1998). Documentation of discharge planning: Im-and hazard modification in preventing falls. Paper presentedproving post-acute care outcomes for older people. Sydney:at OT Australia 20th National Conference, Canberra.Centre for Health Outcomes Innovation Research, UniversityHair, J. F., Anderson, R. E., Tatham, R. L., andBlack, W. C.of Western Sydney Macarthur.(1992). Multivariate data analysis with readings. New York:Christenson, M. A. (1990a). Enhancing independence in the homeMacmillan.setting. Physical andOccupational TherapyinGeriatrics,Hornbrook, M. C., Stevens, V. J., Wingfield, D. J., Hollis, J. F.,8(3/4), 4965.Greenlick, M. R., &Ory, M. G. (1994). PreventingfallsChristenson, M. A. (1990b). Designing for the older person byamongcommunitydwellingolder persons: Resultsfromaaddressingenvironmental attributes. Physical andOccupa-randomized trial. The Gerontologist, 34, 1623.tional Therapy in Geriatrics, 8(3/4), 3148.Josephson, K. R., Fabacher, D. A., & Rubenstein, L. Z. (1991).Clemson, L. (1997). Home fall hazards: A guide to identifyingHome safety and fall prevention. Clinics in Geriatric Medi-fall hazards in the homes of elderly people and an accompani-cine, 7, 707731.ment to the assessment tool The Westmead Home Safety As-Kellogg International Work Group on the Prevention of Falls bysessment (WeHSA). West Bruswick, Victoria: Co-Ordinatesthe Elderly. (1987). The prevention of falls in later life. DanishPublications.Medical Bulletin, 34(Suppl. 4), 124.Clemson, L., Cusick, A., & Fozzard, C. (1999). Managing riskLaferriere, R. H., Palermo, S. E., Scribner, D. W., & Rutledge,and exerting control: The experience of older women receivingK. L. (1998). Rural research: Piloting a tool to identify homehome safety advice to reduce the risk of falls. Disability andcare clients risk of falling. Home Care Provider, 3(3),Rehabilitation, 21(12), 531541.162168.Clemson, L., Fitzgerald, M. H., &Heard, R. (1999). ContentLange, M. (1996). The challenge of fall prevention in home care:validity of an assessment tool to identify home fall hazards.Areviewoftheliterature. HomeHealthcareNurse, 14(3),The Westmead Home Safety Assessment. British Journal of198206.Occupational Therapy, 62, 171179.Lord, S. R., Ward, J. A., Williams, P., & Anstey, K. J. (1994).Clemson, L., Fitzgerald, M., Heard, R., & Cumming, R. (1999).Physiologicalfactorsassociatedwithfallsinoldercommu-Inter-rater reliability of a home falls hazards assessment tool.nity-dwellingwomen. Journal of theAmericanGeriatricsOccupational Therapy Journal of Research, 19, 83100.Society, 42(10), 11101117.Clemson, L. M., Roland, M., & Cumming, R. G. (1992). Occupa-Mah, K. (1996). Home safe home. Perspectives, 20, 79.tional therapy assessment of potential hazards in the homesMann, W. C., Hurren, D., Charvat, B., &Tomita, M. (1996).of elderly people: An inter-rater reliability study. AustralianDifferences between fallers and non-fallers in the frail elderly.Occupational Therapy Journal, 39, 2326.Technology and Disability, 5, 355369.Clemson, L., Roland, M., &Cumming, R. (1997). Types ofMcLean, D., & Lord, S. (1996). Falling in older people at home: hazards in the homes of elderly people. Occupational TherapyTransfer limitations and environmental risk factors. Australian Journal of Research, 17, 200213.Occupational Therapy Journal, 43, 1318. Connell, B. R., & Wolf, S. L. (1997). Environmental and behav-Moss, A. B. (1992). Aretheelderlysafeathome?Journalof ioral circumstances associated with falls at home among healthindividuals. Archives of Physical Medicine, 78, 179186. Community Health Nursing, 9, 1319.Johnson et al.: Home-Screen Scale 177National Health and Medical Research Council (NHMRC). Reinsch, S., MacRae, P., Lachenbruch, P. A., &Tobis, J. S.(1992). Attemptstopreventfallsandinjury:Aprospective (1993). Falls and the older person: Series on clinical manage-ment problemsintheelderly(No. 6: Report oftheHealth community study. Gerontologist, 32, 450456.Rodriguez, J., Sattin, R. W., Devito, C. A., Wingo, P. A., & the Care Committee Expert Panel for Health Care of the Elderly).Canberra: Australian Government Publishing Service. StudytoAssess Falls AmongtheElderlyGroup. (1991).Developing an environmental hazards assessment instrument Norton, R., Campbell, A. J., Lee-Joe, T., Robinson, E., & Butler,M. (1997).Circumstancesoffallsresultinginhipfractures for falls among the elderly. In R. Weindruch, E. C. Hadley, &M. G. Ory, (Eds.), Reducing frailty and falls in older persons. among older people. Journal of the American Geriatrics Soci-ety, 45, 11081112. Springfield, IL: Charles C. Thomas.Schlapman, N. (1990). Elderlywomenandfallsinthehome. New South Wales (NSW) Health. (1995). Falls prevention: Yourhomesafetychecklist. Takestepstopreventafall. Sydney, Home Healthcare Nurse, 8, 2024.Schoenfelder,D. P.,&VanWhy,K.(1997).Afallprevention Australia: NSWDepartment of Health, HealthPromotionUnit. educational program for community dwelling seniors. PublicHealth Nursing, 14, 383390. Nunnally, J. C. (1978). Psychometric theory. New York:McGraw-Hill Publishing Company. Thompson, P. G. (1996). Preventing falls in the elderly at home:A community based program. Medical Journal of Australia, OBrien, K., Pickets, B., & Culham, E. (1998). Clinical measuresof balance in community-dwelling elderly female fallers and 164, 530532.Tideiksaar, R. (1989). Home safe home: Practical tips for fall- non-fallers. Physiotherapy Canada, 50(3), 212217,221.Plautz, B., Beck, D. E., Selmar, C., &Radetsky, M. (1996). proofing. Geriatric Nursing, 10(6), 280284.Tinetti, M. E., & Williams, C. S. (1997). Falls, injuries due to Modifying the environment: Acommunity based injury-reduction program for elderly residents. American Journal of falls, and the risk of admission to nursing home. New EnglandJournal of Medicine, 337, 12791273. Preventative Medicine, 12, 3338.Ploeg, J., Black, M. E., Hutchison, B. G., Walter, S. D., Scott, E. Weber, J.,Kehoe, T., Bakoss,M., Kiley,M., &Dzigiel,J. M.(1996). Safety at home: A practical home injury control pro- A., &Chambers, L. W. (1994). Personal, home and communitysafety promotion with community dwelling elderly persons: gram for independent seniors. Caring, 15(6), 6266.Williams, M. W., & Nolan, M. (1993). Prevention of falls among Responsetoapublichealthnurseintervention. CanadianJournal of Public Health, 85, 188191. older people at home. British Journal of Nursing, 2, 609613.Willis, S. (1998). Fallsinelderlypeople: Istherisksuitably Ray, W. A., Taylor, J. A., Meador, K. G., Thapa, P. B., Brown,A. K., Kajihara, H. K., Davis, C., Gideon, P., & Griffin, M. assessed? British Journal of Nursing, 7(2), 12591262.Wolter, L. L., & Studenski, S. L. (1996). A clinical synthesis of R. (1997). Arandomizedtrial of aconsultationservicetoreduce falls in nursing homes. Journal of the American Medi- fallsinterventiontrials. Topicsof GeriatricRehabilitation,11(3), 919. cal Association, 278(7), 557562.Reed, K. L., &Sanderson, S. N. (1999). Concepts of occupationaltherapy. Philadelphia: Lippincott, Williams, & Wilkins.Copyright of Public Health Nursing is the property of Wiley-Blackwell and its content may not be copied oremailed to multiple sites or posted to a listserv without the copyright holder's express written permission.However, users may print, download, or email articles for individual use.