Wishes and needs of older persons who have experienced a fall: A qualitative study

Abstract Aim The aim of this study was to explore the needs and wishes in everyday life of older persons who have experienced a fall. Design A hermeneutic‐phenomenological design with semi‐structured interviews. Method Interviews were analysed using systematic text condensation. Results Nine patients (5 women, 4 men) were included. The participants were between 67–95 years old. Seven of the nine participants had suffered from recurrent falls. The analysis revealed four themes: “To maintain meaningfulness in everyday life after experiencing a fall”, “Contact with professionals can be a prerequisite for feeling well and motivated after a fall”, “A need for assistive technology and aids in everyday life” and “Asking for help can be a challenge”. Our findings highlight that older‐person‐centred care and treatment are essential to address the complex variations in needs and wishes of older persons who have experienced a fall.

in a decline in health status, ability to undertake activities of living, lifestyle and quality of life (Roe et al., 2009), but also that some accept fear of falling as a part of life (Mahler & Sarvimaki, 2012) and that older people can be embarrassed about wearing visible falls detection technology (Charlton, Murray, & Kumar, 2018). Furthermore, it has been reported that older women make a range of postfall responses and decisions, including engaging in the extra work required to get back to normal, purposefully avoiding people, objects and places, being proactive and planning ahead and putting the fall out of mind (Bergeron, Friedman, Messias, Spencer, & Miller 2016).
Finally, indications from prior reports state that health professionals frequently fail to refer people to fall prevention interventions (Dickinson et al., 2011)

| ME THOD
The study is reported using the consolidated criteria for reporting qualitative studies (COREQ; Tong, Sainsbury, & Craig, 2007).

| Theoretical framework and study design
A hermeneutic-phenomenological approach was used together with a qualitative explorative design. Semi-structured interviews were used to gather data to identify the variations in perspectives, thoughts and experiences regarding older persons needs and wishes in their everyday life after experiencing a fall (Vallgårda & Koch, 2011).

| Participants and setting
Purposive sampling (Maxwell, 2013) was used to include participants, and 10 older persons (five men and five women) above 65 years of age were invited to participate in the study. One person resigned from participation. The recruitment was conducted at the Falls Clinic at Department of Geriatric Medicine, Odense University Hospital, Denmark between 9 September 2017 and 6 December 2017. The nurses at the Falls Clinic acted as gatekeepers for getting in contact with the participants. We included persons who were cognitively well-functioning (defined as Mini-Mental State Examination above 24 points; Folstein, Folstein, & McHugh, 1975), were living in their own home and were able to speak and understand Danish.
All participants had experienced a fall within the last 3 months, and none had suffered any fractures.

| Data collection
The semi-structured interviews were conducted using an interview guide containing six guiding questions, which was developed through literature search, experiences from clinical practice and discussion among authors (Table 1). Each interview started with an open question such as "Would you please tell me about your everyday life" to create a relaxed atmosphere and encourage the participants to give an answer using their own words and knowledge. The main author ASB was the interviewer in all the interviews which were held within a week after the participants were asked to participate.
The interviews took place in the participants' own home, which was decided by all participants and supported by the research team.
The reason for this was to make sure that the participant was in a well-known environment, as well as eliminating the possible problems with transportation for the participant. In four out of nine interviews, a relative passively participated and sat next to the participant. By including the family member into the interview setting, a trusting environment was created in the interview situation, which helped the participant to share stories, experiences and thoughts.
To validate data from the interviews, the interviewer used the method of reflective listening (Rollnick, Miller, & Butler, 2008), a method where the interviewer repeats the key elements of what the participant has expressed, to secure that all important information is gathered in the right way and thoroughly understood.

| Analysis
The transcribed interviews were analysed by the method systematic text condensation (Malterud, 2012). This method consists of the following steps: (a) total impression-from chaos to themes. In the first steps of the analysis, a phenomenological approach was used. The aim was to get a general overview of the whole material. Thus, all interview transcripts were read several times; (b) identifying and sorting meaning units-from themes to codes. In the second step, we TA B L E 1 Interview guide (c) condensation-from code to meaning. In step three, the meaning units were reread several times and the content was reduced into a condensate-an artificial quotation maintaining, which as far as possible has the original terminology applied by the participants; and (d) synthesizing-from condensation to descriptions and concepts. In the fourth step of the analysis, a hermeneutical approach was added to the analysis (Vallgårda & Koch, 2011). In this final step, the aim was to understand and interpret the condensations and synthesize the contents of the condensates into the final descriptions regarding the participants' experiences and perspectives regarding their needs and wishes.
All coding and analysis were performed systematically using the software QSR NVIVO Pro 11. Table 2 shows a schematic example of the steps in the analysis process from meaning unit to condensation, description and theme title.

| Ethical considerations
The Danish Data Protection Agency approved the study in accordance with the Act on Processing of Personal Data No. 17/31527.
Approval by an official ethics committee was not required according to Danish law. All participants were informed that participation was voluntary, and they could withdraw from the study at any time without explanation. Informed written and verbal consent was obtained from all participants.

| RE SULTS
A total of nine persons were included in the study and completed the interviews. The participants were between 67-95 years old.
The interviews lasted approximately 1 hr and were recorded and subsequently transcribed verbatim. The characteristics of the study participants are listed in Table 3. The participants' initials have been altered in this article to avoid identification. As shown in Table 3,

| Theme I: to maintain meaningfulness in everyday life after experiencing a fall
The first theme of the analysis revealed that all participants ex- After experiencing a fall, all participants expressed the importance of not being dependent on others. It was a great wish to be able to do the things they wanted to do in their daily living, like TA B L E 2 Schematic example of the steps in the analysis process from meaning units to condensation, to description and theme title  Participating in training was described as generating not only physical benefits, but also social and emotional benefits and was expressed as a "highlight of the week": The participants also emphasized that the health professionals at the Falls Clinic had a holistic approach in their way of treating the patients, and this was highly praised among the participants:

| Theme II: contact with professionals can be a prerequisite for feeling well and motivated after a fall
They do a great job to get around the whole person (BF) The participants felt that the health professionals had skills, which embraced the whole person and not just one single part of the body, which was expressed as needed to receive help and care that was in accordance with the daily life of older persons who have experienced a fall.

| Theme III: a need for assistive technology and aids in everyday life
The third theme of the analysis illustrated that participants expressed a need for assistive technology and aids in their everyday life after a fall event to feel safe and independent from others. The need of assistive technology and aids was based on a wish for preventing another fall as well as a wish for assistance in the event of a fall. Mobile walkers were perceived as being able to reduce the risk of further falls, and an emergency call device was expressed as a lifeline for receiving help if the older person was to experience another fall. By expressing these needs, the participants were planning ahead and wanted to implement safety technologies to help managing and preventing further falls.
The analysis showed that the request for assistive technology and aids was only expressed by female participants. Some male participants expressed that planning ahead and thoughts about fall prevention were just not present in their minds because they did not think about their fall experience in their everyday life.

| Theme IV: asking for help can be a challenge
As a fourth theme, the analysis identified a group of participants who had difficulties expressing their wishes and needs in their everyday life after they had experienced a fall and some of these participants directly rejected any need for help in their daily living. This group of participants felt no need to contact health professionals and had no need for going to the hospital although they had experienced one or more falls: It was the Falls Clinic that called me. I would never have gone to the hospital myself (CM) These participants did not perceive their fall as a problem, but as a result of either "bad luck" or as an age-related phenomenon, which was unavoidable. The participants seemed not to be aware of the possibilities of getting professional help, help supplies or treatment to optimize their everyday life.
For some participants, it was of great importance to clarify that they, despite their fall experience, were independent and able to manage the daily life by themselves: Help is the last thing I'll ask for. As long as I can handle it without help, no one will be called. I have both wall- Going from a feeling of being a healthy fit man to the one who is in need of help and is getting in touch with the healthcare system contributed to the feeling of adopting a new identity as an "older frail person", and thus the need for help was being denied and rejected.
Both men and women were present in this group of participants; however, we found most of the men rejecting the need for help and being silent about their needs and wishes after their fall experience. To our knowledge, this is the first study to explore the needs and wishes in everyday life of older persons who have experienced a fall. But our findings contribute to other studies showing that effective health care from a highly competent staff is valued and wished for among older people (Hallgren, Ernsth Bravell, Dahl Aslan, & Josephson, 2015). These findings also contribute to the statements by WHO, outlining that it is highly important that health professionals and caregivers are aware of the great variation in patients wishes and needs and that healthcare services must provide older-personcentred care which meets the needs of the individual older person, not only focusing on the specific disease (Beard et al., 2016;WHO, 2018).

| D ISCUSS I ON
Regarding the need and wish for assistive technology, another study likewise reported that medical devices are needed and valued (Schoberer, Breimaier, Mandl, Halfens, & Lohrmann, 2016).
Additionally, our analysis reveals that the wish for assistive technology and aids has a tendency to be gender-dependent since only female participants requested this. Similarly, Bergeron et al. (2016), assessing older women's responses and decisions after a fall, reported that several women were planning ahead and implementing safety measures to help manage and prevent future falls (Bergeron et al., 2016). Correspondingly, a study with both men and women reported how a male participant believed that his pride was a barrier for making contingency plans. The male participant did not like using assisting devices (such as his four-wheeled walker), which he believed would stigmatize him as someone who needed help (Charlton et al., 2018). These findings therefore indicate that the need for assistive technology and aids could be even higher than shown in our study, but male persons might have refrained in expressing these needs after their fall experience.
In contrast to the group of participants who expressed a great need and wish for getting professional help and assistive technology and aids into their everyday life, our study furthermore identified a group of older fallers, who acted silently and did not express any expectations or needs for professional help after their fall experience. In line with this, McInnes et al. found that a fall was not necessarily categorized as a health problem but more as either a result of "just sheer accidents" or because of inattention rather than to a persistent vulnerability (McInnes et al., 2011). Furthermore, they found that being at risk of falling was perceived as being synonymous with frailty and therefore not relevant to those who did not perceive themselves in that way (McInnes et al., 2011). In this way, the denial of need for treatment and help in our study might reflect a desire to maintain independence and not being willing to make any changes (Pereles, Jackson, Rosenal, & Nixon, 2017). However, this expression of no need for help in everyday life after a fall event could also be explained by a lack of information and knowledge about the possible treatment and prevention services regarding fall experiences. Nevertheless, if the expression of being in no need for help is influenced by either lack of knowledge or is based on a denial of needs, there is room for providing better information in society.
Older persons' refusal or non-uptake of services are not an objective free choice but rather the result of a set of external and potential modifiable circumstances (Howse, Ebrahim, & Gooberman-Hill, 2004). On the basis of this, we therefore encourage health organizations and municipalities to provide information to older citizens to supply them with sufficient knowledge, so older persons are able to know, judge and express what they wish and need in their everyday life after experiencing a fall. The provided information should contribute in a way that older individuals do not feel a lower self-esteem because they have fallen and then keep away from expressing needs for help because they do not want a label of a "frail old faller". It is of utmost importance that fall information and advice is formed and communicated in a way that do not let older persons feel stigmatized (Yardley, Donovan-Hall, Francis, & Todd, 2006). A way to address this complex topic is to involve older people in service planning (Howse et al., 2004). Our study emphasizes that future research and the healthcare system, in general, should develop targeted initiatives that address older persons who are having difficulties expressing needs and wishes in their everyday life after experiencing a fall.

| Limitations
In qualitative research, it is often discussed when data saturation are achieved and in our case with only nine participants this might be relevant. However, due to the uniqueness of each person, it can be argued that no data can be truly saturated (Wray, Markovic, & Manderson, 2007). The fact that eight of the nine participants were recurrent fallers might have influenced the results. However, we did not find any association between the recurrent fallers and their perspectives and answers in the interviews. Further research including a larger sample size might contribute to this element.
Our study was a single centre study performed in Denmark based on the certain context, setting and the conditions of the participants. Therefore, it might not be possible to generalize our results to other older persons. However, our results give new insights that can be transferred to other groups of older persons in similar settings and within countries which are comparable to Denmark. Finally, we excluded residents living in nursing homes, patients not speaking Danish and cognitively disabled persons. In this way, the study does not represent the general outpatient fall population since the study focuses on a limited group of well-functioning community-dwelling older persons. However, we aimed for maintaining a homogeneous group of patients with a degree of variability into the sample (in terms of age, gender, civil status and type of accommodation) to get powerful results related to this type of population. To assess possible variations in patient- reported outcomes, future studies should include the even more vulnerable and frail patient groups. Thus, we recommend that further research should explore the wishes and needs after a fall experience in older persons living in nursing homes, older persons with minority background and older persons who are cognitively disabled.

ACK N OWLED G EM ENTS
The authors thank the participants, for sharing their experiences.

CO N FLI C T O F I NTE R E S T
The authors have no conflicts of interests.

AUTH O R CO NTR I B UTI O N
ASB, JR and DN: conception and design of the work. All authors made substantial contribution to the analysis and interpretation of data. ASB and DN: first draft preparation. All authors revised it critically for important intellectual content. All authors approved the final version for publication and agree to be accountable for all aspects of the work.