Public Health Nursing Vol. 18 No. 3, pp.

169177
0737-1209/01/$15.00
Blackwell Science, Inc.

Home-Screen: A Short Scale to

Measure Fall Risk in the Home
Maree Johnson, R.N., Ph.D.,
Anne Cusick, B.App.Sci., Ph.D., and
Sungwon Chang, B.Sc., M.Stats.

Abstract Community nurses are often the health professionals

with whom older Australians living at home have most contact.
The home environment has been identified to have a number of
hazards associated with falls in older people. The Home-screen
scale was specifically designed as a nurse-administered instrument to identify environmental and behavioral risks that alert
nurses to the need for action to reduce fall risks in the home. A
14-item scale was administered to 1,165 older people receiving
community nursing services. Psychometric investigation confirmed a 10-item scale with construct validity and internal consistency ( 0.86, n 989), explaining 60% of the construct of
home safety (safe home environment and safe home behaviors).
In addition, differences in mean scores were found in clients able
and unable to transfer independently (t 4.5 [df 323.1] p <
0.001 [Group 1: M 82.14, SD 15.56; Group 2: M 75.54,
SD 20.83, n 989]). Similarly, an association existed between
clients with low scores on the Home-screen scale and the perceived need for home modification. A score of 74 on this scale
has been identified as a critical point for potential client injury.
The use of this scale, both as an initial screening instrument and
Maree Johnson is Research Professor, Co-Director, Health at
Home Research Center, Faculty of Health, University of Western
Sydney, Macarthur, Campbelltown, Australia. Anne Cusick is an
Associate Professor, Member Health at Home Research Center,
Division of Occupational Therapy, Faculty of Health, University
of Western Sydney, Macarthur, Campbelltown, Australia. Sungwon Chang is a Lecturer, Division of Public Health, Faculty of
Health, University of Western Sydney Macarthur, Campbelltown,
Australia.
The authors wish to express their thanks to the Commonwealth
Department of Veterans Affairs. The views of these authors do
not reflect those of the Commonwealth Department of Veterans
Affairs.
Address correspondence to Maree Johnson, Faculty of Health,
University of Western Sydney Macarthur, P.O. Box 555, Campbelltown, Australia 2560. E-mail: m.johnson@uws.edu.au

as a monitoring tool for community nurses working with older

people, is recommended.
Key words: community nursing, occupational therapy, falls.

INTRODUCTION
One in three older people living in the community will
experience a fall this year (El-Faizy & Reinsch, 1994). An
important area of risk for falls by older people is the home
environment and the way in which older people use the
home (Connell & Wolf, 1997; Josephson, Fabacher, &
Rubenstein, 1991). This makes safety in the home a public
health issue of national and international importance.
Falls represent a major cause of injury in older populations in the United States (Connell & Wolf, 1997). Similar
patterns of morbidity and mortality exist in Australia (Australian Institute of Health and Welfare [AIHW] and Commonwealth Department of Health and Family Services
[DHFS], 1997; McLean & Lord, 1996), Canada (Ploeg et
al., 1994), and the United Kingdom (Donald & Bulpitt,
1999). Quality of life for older people is also affected by
falls, through a subsequent fear of falling (McLean & Lord,
1996). Such fear of falling represents a major contributing
factor to nursing home admissions (Tinetti & Williams,
1997).
Home modification and change in behavior when using
the home are central strategies to prevent falls (Christenson,
1990a; National Health and Medical Research Council
[NHMRC], 1993). Both strategies aim to make the home
and home-related behavior safer by minimizing hazards
and risk-taking.
Community nurses play a vital role in the early identifi-

169

170 Public Health Nursing

Volume 18 Number 3 May/June 2001

cation of fall risk. This study sought to develop and test

a short screening tool for community nurses to assess home
safety by measuring features of the home environment and
behaviors of the older person when using the home. With
such information, community nurses will be able to reduce
fall risk either through targeted nursing interventions or
through referral to specialist home modification and home
behavior services.
LITERATURE REVIEW
A fall has been defined as an unintentional event where
a person comes to be on the floor without the feet weightbearing (Reinsch, MacRae, Lachenbruch, & Tobis, 1992,
p. 5). Falls are the result of a complex interaction between
the older person (intrinsic factors) and the environment
(extrinsic factors) and the behavior of older people. As
Josephson et al. stated: many falls attributed to accidents
. . . stem from interactions between environmental hazards or hazardous activities and increased susceptibility to
hazards from the accumulated effects of age and disease
(1991, pp. 709710).
Intrinsic factors are age-related, and possibly diseaserelated changes that alter the persons ability to negotiate
the environment intrinsic factors. Intrinsic factors include
health problems, such as altered physical functioning
(Christenson, 1990a; Lange, 1996; Lord, Ward, William, &
Anstey, 1994; Mann, Hurren, Charvat, & Tomita, 1996;
OBrien, Pickles, & Culham, 1998). Polypharmacy and
medications such as hypnotics, sedatives, antihypertensives, and cardiovascular drugs, have also been implicated
(Lange, 1996; Mann et al., 1996). Although programs to
increase functionality, strength, and balance have met with
varying success (Wolter & Studenski, 1996), most intrinsic
factors are multidimensional and not readily amenable to
change (Fortin, Yeaw, Campbell, & Jameson, 1998, p.
628). This has led to interest in extrinsic factors as possible
targets for falls prevention.
Extrinsic factors are those things in the environment that
are hazardous (Lange, 1996). The home environment is of
particular interest for older people. A detailed report on
the location of 242 falls emphasized that most falls occurred
in the home (32.2%), surrounding transition area (16.1%),
and outside (51.2%) (Reinsch et al., 1992). Environmental
features such as poor lighting, slippery rugs, clutter, and
handrails play a part in a third to half of falls by older
people in homes (Hornbrook et al., 1994; Rodriguez, Sattin,
Devito, Wingo, & the Study to Assess Falls Among the
Elderly, 1991). Assistive devices also contribute to falls
and include walkers (Fleming & Pendergast, 1993) and
vision devices (Mann et al., 1996).
The behavior of the older person in the environment
must also be considered. It has been found that older people

may engage in particular behaviors that increase the risk

of a fall (Connell & Wolf, 1997; Ploeg et al., 1994; Reinsch
et al., 1992). These may be habitual or inappropriate behaviors (Connell & Wolf, 1997), including rushing to get the
door, or getting up to go to the toilet at night without
adequate lighting.
Falls prevention strategies need to target these three
areas of risk: intrinsic factors, extrinsic factors, and the
behavior of individuals as they engage with the environment. As intrinsic factors have been identified as particularly difficult to address (Fortin et al., 1998), the home
environment has been suggested to be a promising area of
intervention and prevention for older people. There is some
evidence that management of extrinsic factors such as home
assessment and modification for safety can reduce falls in
older people (Norton, Campbell, Lee-Joe, Robinson, &
Butler, 1997; Ray et al., 1997). A recent randomized control
trial revealed that detailed home assessment and intervention by an occupational therapist reduced falls particularly
with people at high risk of falling (Cumming, Thomas,
Szonyi, & Salkeld, 1998; Frampton, Cumming, & Thomas,
1999). Differing viewpoints and meanings about a home
(Christenson, 1990b), however, can make environmental
modification difficult (Clemson, Cusick, & Fozzard, 1999;
El-Faizy & Reinsch, 1994). For instance, older people
may remain reluctant to alter their homes unless they have
experienced a fall (El-Faizy & Reinsch, 1994). This suggests that home environmental change may not always be
a possible falls prevention strategy (Clemson, Cusick et
al., 1999; Schoenfelder & Van Why, 1997).
Community nurses are often the health professionals
with whom older people living at home have most contact.
A recent study in the United Kingdom by Willis (1998)
identified that district nurses were the most likely group
of professionals to screen older people (75 years and older)
for the risk of falling. But what instruments do these nurses
use to assess risk? Willis surveyed health centers or individual practitioners in six counties in England and Wales and
found that 97% of the respondents did not use a tool. When
tools were used, however, they were found to be unsuitable
for assessing risk of falling within the home environment
(Willis, 1998). A similar situation exists in Australia and
possibly in other countries.
Community nurses undertake a comprehensive biopsychosocial assessment of the client and often rely on occupational therapists to undertake environmental assessments.
Traditionally, assessment and modification of the home
environment has been a specialized service delivered by
occupational therapists (Clemson, 1997). The problem,
however, is that the vast majority of older people do not
come into contact with occupational therapists to receive
this assessment and modification service (Bye et al., 1998).
Most older people do not interact with occupational

Johnson et al.: Home-Screen Scale 171

therapists because occupational therapists are not available,

the referral to occupational therapy is not made, or the
referral is made too late (Bye et al., 1998). The lack of
specialist occupational therapist service is often seen in
rural areas, as evidenced in a recent study to develop a home
hazards tool for rural communities (Laferriere, Palermo,
Scribner, & Rutledge, 1998). As key coordinators of the
health of older people, it is important that community
nurses have the ability to assess environmental risk.
There are several home environment assessment tools
available of varying measurement quality (Rodriguez et
al., 1991). Many of these have been designed by and for
occupational therapists, with specialist skills and knowledge in the area of environmental assessment, adaptation,
and adjustment for people with special needs (Clemson,
Roland, & Cumming, 1992, 1997; Cooper, Cohen, & Hasselkus, 1991; Reed & Sanderson, 1999). The most commonly used and widely available occupational therapy
instrument in Australia is the Westmead Home Safety Assessment (WeHSA) (Clemson, 1997). This criterion referenced instrument has been examined for face validity,
content validity, and reliability and it appears acceptable
for clinical use (Clemson, Fitzgerald, & Heard, 1999;
Clemson, Fitzgerald, Heard, & Cumming, 1999). The tool,
however, is lengthy and requires specialist training and is
therefore unsuitable for use by community nurses.
In addition to occupational therapy instruments, there
are many checklists used in health promotion programs
and falls research that present environmental features that
may be considered a risk for falling, especially by older
people. These may include lists: identifying rooms and
spaces where falls can occur (Fleming & Pendergast, 1993),
specific hazards in each room of the house (Josephson et
al., 1991), home safety inspection (Thompson, 1996)
and home safety assessment, (Plautz, Beck, Selmar, &
Radetsky, 1996), and finally, of rooms, hazards, and behaviors of concern. The weakness of many of these instruments
is that little or no information regarding the quality of these
measures is presented in such checklists.
There are also a number of self-administered instruments
that have been developed as health promotion tools. These
require the respondent, usually assumed to be an older
person, to identify listed hazards and check whether or not
they are present or could be removed or changed. Some
examples of self-administered tools include the Falls Prevention: Your Home Safety Checklist (New South Wales
[NSW] Health, 1995) and the well known Home Safety
Checklist (Kellogg International Work Group on the Prevention of Falls by the Elderly, 1987).
As nurses are key providers of direct care in the community, there is a need for an instrument, in addition to the
wide range already available, which can be easily and
quickly be administered by community nurses as part of

their routine practice. Such an instrument can provide the

information needed to identify home hazards requiring either targeted nursing action or referral for specialist occupational therapy assessment and home modification
intervention. Similarly, hazardous home behavior that is
amenable to nursing intervention can be identified and
acted upon when necessary.
This study aims to develop a short instrument to be
used by community nurses to identify features in the home
environment that could be considered hazards to older
people and behaviors that could be indicative of unsafe
practices that could result in injury. This study will also
examine the instruments construct validity and internal
consistency.
METHOD
This study used secondary data analysis techniques to examine the validity and reliability of the Home-screen scale.
The original data were supplied to the National Exceptional
Case Co-Ordination Unit (a community nursing support
system of the Commonwealth Department of Veterans
Affairs [DVA]). This support service centrally manages
information on a wide variety of veteran characteristics
and nursing activities to generate funding levels and supply
summary information to service providers and funding
agencies on veterans with intense community nursing care
needs and consequent cost. A subset of these data, collected
by community nurses from April to June in 1998, was
extracted in a de-identified form from the central database
and used to undertake these analyses.
Sample
The sample consisted of 1,165 veterans receiving care from
community nursing services of the DVA. Veterans came
from any part of Australia including remote, rural, and
metropolitan communities. The mean age of veterans was
81 years and 58% were male (see Table 1). Most veterans
had low levels of dependency (863/1,166; 74%) with 46%
having a coresident caregiver. Overall this sample reflected
a group of clients with poor to fair health (929/1,112;
83.5%). The two principal medical diagnoses frequently
occurring in this sample were stroke and osteoarthritis,
although these were small in number. A diverse range of
diagnoses applied to this sample (see Table 1).
Instrument
The Home-screen scale was specifically designed as a
nurse-administered instrument to identify environmental
hazards and unsafe behavior and alert nurses to the need
for specialized environmental assessment and behavior
change. A review of the literature revealed that a wide
range of environmental features and home behaviors were

172 Public Health Nursing

Volume 18 Number 3 May/June 2001

TABLE 1. Subject Characteristics

Characteristic
Age in years
Gender
Male
Female
Self-rated health
Poor
Fair
Good
Very good
Excellent
Activities of daily living
High dependency*
Low dependency
Carer availability
Beneficiary independent or has no need for carer
No carer available
Has a co-resident carer
Has a nonresident carer
Lives in a mutually dependent situation
Not applicable/in residential care
Principal medical diagnosis (top 5 only)
Stroke/CVAlate effects hemiplegia
Osteoarthritisgeneralized, multiple sites
Airways obstructionchronic
Malignant neoplasm
Ulcer, lower limbs

Mean

1,165
674
488

80.77 (SD 7.13)

Percentage
57.8
41.9

455
474
157
21
5

40.9
42.6
14.1
1.9
0.4

303
863

26.0
74.0

66
300
534
168
52
39

5.7
25.7
45.8
14.4
4.5
3.3

148
104
91
82
68

12.7
8.9
7.8
7.0
5.8

*High dependency was determined by using three items from the Community Nursing Minimum Dataset activity of daily living
scale (ACCNS, 1994; 1997). High dependency occurs when the client is dependent (score greater than 1) in transfer and bathing/
showering, dressing, or toileting.
Low dependency was inferred when the client was independent (score of 1) in transfer, bathing/showering, dressing, or toileting.

included in tools designed to assess home hazards. The

literature also revealed little information about what particular features and behaviors were predictive of falls. The
investigators used their knowledge of community nurse
activity, within the context of home visits, to identify features of the environment and home behavior that could be
easily observed or would be readily known about community nursing clients. As the pilot instrument was specifically
developed to be a short scale, the investigators kept the
instrument limited in size.
Further deliberation by the investigators concluded that
there was a need to avoid special training in a screening
instrument, whilst retaining those home behaviors and features that could be readily observed by community nurses.
Fourteen aspects were chosen by the investigators from
the array of possible features and behaviors presented in
the literature. These aspects formed the items in the new
scale.
Seven environmental features formed the items included:
room clutter, good lighting for day and night, floor cov-

erings, shoes worn in the home, toileting, and showering

facilities. Each item was rated from 1 to 10 with intervals
of 1, with a score of 10 representing a home where every
room was free of clutter.
Home behaviors important for safety and easily observed
by nurses were also considered. Seven items were included
in the home behavior subscale: the use of clean toilet
facilities or aids, moving carefully through the house, wearing footwear correctly, taking care when doing things, night
lighting when getting up, climbing to reach high items,
and hurrying to answer telephone or door (reverse scoring
applies). Similar scoring systems to that used in the home
environment subscale were used. Total subscale scores
ranged from 7 to 70.
Procedure
The Home-screen scale was included in a survey form that
was completed by community nursing. This community
nursing survey form included a range of areas such as:
demographics, disease patterns, health rating, specific be-

Johnson et al.: Home-Screen Scale 173

haviors (such as falling), nursing care requirements, social

support, cognitive function, home environment and home
behavior, and support services required (including home
modification). This form is routinely completed by nurses
in relation to their clients.
RESULTS
Psychometric assessment of the scale consisted of examining the construct validity and internal consistency of the
instrument. Construct validity of the scale was determined
using factor analytical techniques. These techniques gave
an overall sense of how well the scale items (subsequently
formed into factors or groupings of items) described an
underlying latent construct: in this case Home-screen consisted of two subscalesHome-safe and Home-behavior.
Each component of the Home-screen was examined
separately.
Initial exploratory factor analysis and reliability assessment on 14 items suggested deletion of two items (person
climbs to reach high items and person hurries to answer
telephone or door [Home-safe]) because of low factor
loading and low item to total correlation (r 0.21, r
0.17, respectively). The remaining 12 items were analyzed
using factor analysis and varimax rotation. Subsequent
varimax rotation was then undertaken to assist in the interpretation of a possible 3 factor solution accounting for
66% of the variance of Home-screen. On close examination
of the items, however, two additional items were loading
on two factors (factor loadings > 0.40)toileting facilities and items are easy to reach and use at night (from
Home-safe), and person uses stable, clean toileting facilities or aids (from Home-behavior). After deleting these
two cross-loading items, further analysis was suggestive
of a configuration of 10 items within two factors. When
principal components factor analysis was programmed to
produce 2 factors to correspond to the predetermined 2
subscales of the instrument (home safe and behavior), it
accounted for 60% of the variance (see Table 2) and demonstrated a two factor solution on scree plot. Examination of
the factor matrix showed one item loaded more appropriately on the Home-behavior subscale than the originally
designed Home-safe subscale: shoes usually worn at
home fit well and have good traction on heels and soles
(home-safe). The best factor solution appears in Table 2
and includes the relocation of the above item. Table 2
highlights the high factor loadings (0.650.81) for all items.
Differences in Known Groups
Another approach to confirming the underlying construct is
to examine differences in the instrument with groups that
would be perceived as likely to differ on the scale. In this
case, the item relating to transfer from the Community Nurs-

ing Minimum Data Set Australia (Australian Council of

Community Nursing Services, Inc. [ACCNS], 1997) was
used to distinguish older people requiring assistance with
transfer and those not requiring assistance (no assistance required in transfer [1] or physical assistance required [2]). All
clients with a complete set of scores for the Home-screen
scale and dependency transfer item (N 989) were grouped
into independent on transfer (n 752, Group 1) and dependent on transfer (n 237, Group 2). An independent t test,
with equal variances not assumed, was then undertaken confirming that there was a significant difference between the
groups(t 4.5 [df 323.1] p < 0.001) (Group 1: M
82.14, SD 15.56; Group 2, M 75.54, SD 20.83).
Nonparametric procedures were also used, as these data were
not normally distributed, and similar results were obtained.
Reliability (Internal Consistency)
The reliability of the overall scale and subscales, known
as internal consistency, was determined using Cronbachs
alpha. This statistic was calculated separately for the items
comprising the 2 factors and for the entire scale. The resultant alpha coefficients were: 0.84, Home-safe subscale (5
items); 0.81, Home-behavior subscale (5 items); and 0.86
for all items or Home-screen. (Table 2).
Critical Points: Potential for Falls and Injury in Older
People
Using the best solution (10 items), the distribution of the
total scores for the total Home-screen scale and total Homesafe subscale and total Home-behavior subscale were calculated. The investigators aimed to produce an instrument
that would prompt nurses to act on home environment or
home behavior hazards either by seeking assistance from
occupational therapists or by implementing targeted nursing interventions where such specialist services were not
available. To provide a prompt for action by nurses using
the scale, a score on the total home-screen scale was sought
that would indicate the need for intervention. This was
considered to be a critical point on the scale that reflected
a threshold of risk.
By using these total scores at the 25th percentile, the
score for the Home-screen scale was 71. This means that
only 25% of this entire sample (247/989) had a score of
71 or less, representing poor home safety and behavior.
Similarly, the 25th percentile score was 36 for the Homesafe subscale and 33 for the Home-behavior subscale. Percentiles, rather than a derived score, have been chosen as
the mean scores for the items, and therefore scales are
generally high. It is also notable that 50% or more of this
sample had a total Home-screen score of 84.
Further confirmation of the utility of the critical point
of 71 was sought by exploring the association between

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TABLE 2. Characteristics of Items in Home-Screen Best Solution: Principal Component Analysis Using Varimax Rotation Method
with Kaiser Normalization for Two Factors Using Ten Items
Item
Home-safe
Rooms/halls are free of clutter
Rooms/halls have good daylight
Rooms/halls have good night lighting
Floor coverings in home are even, firm, and nonslip
Bathing/showering facilities and items are easy to access and use
Home-behavior
Person moves carefully through the house
Person wears footwear correctly
Person takes care when doing things at home
Person puts lights on at night if getting up
Shoes usually worn at home fit well and have good traction on heels and soles

Mean

SD

ITC

Factor 1

Factor 2

7.89
8.10
8.34
8.36
8.36

2.59
2.39
2.27
2.28
2.38

0.67
0.70
0.72
0.63
0.50

0.78
0.84
0.82
0.76
0.60

0.16
0.11
0.20
0.17
0.34

8.04
7.78
7.86
8.19
7.62

2.58
2.99
2.67
2.99
3.00

0.67
0.67
0.65
0.44
0.58

0.20
0.23
0.14
0.01
0.31

0.81
0.75
0.81
0.65
0.65

ITC 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 plot
demonstrates 2 components with an eigenvalue of greater than 1.

veterans with low (scores of 71 or less on the Home-screen

scale) and high (scores greater than 71) home safety and
behavior, and veterans experiencing falls. An item referring
to falling behavior: does the beneficiary experience falling behavior (response never [1], rarely [2], occasionally
[3], frequently [4]) was used to form two groups: Group
1, scores of 3 or less and Group 2, scores of 4. Chi-square
analysis demonstrated that veterans with poor home safety
and behavior (scores of 71 or less on Home-screen) also
experienced frequent falls (2 15.4, df 1, p < 0.001,
n 726). Also it is notable that 74.2% (539/726) of
veterans had a score of more than 71.
It was also possible to use this critical point to form
groups of high and low Home-screen scorers and compare
these with the proportion of veterans perceived by community nurses to require support services used or planned
home modification. Chi-square analysis demonstrated
that a slightly higher proportion of veterans with poor home
safety and behavior (scores of 71 or less on Home-screen)
were also identified as needing or having home modification service, although this was not significant at the 0.05
level (2 2.0, df 1, p 0.097, n 989). Further
analyses were undertaken using a higher critical point of 74
to split the groups. These analyses resulted in a statistically
significant difference (2 4.15, df 1, p 0.047, n
989), with higher proportions of veterans with high Homescreen scores (scores of greater than 74) being perceived as
not requiring home modification services and higher proportions of veterans with low Home-screen scores (scores of
74 or less) being perceived as requiring home modification
services.

DISCUSSION
Health promotion in older people remains an important
and developing role for public health nurses (Davis, 1994).
Falls prevention and tools that assess the potential for
falls, should be included in any comprehensive nursing
assessment of community-living older people (Lange,
1996; Moss, 1992; Williams & Nolan, 1993). This study
sought to develop and test a short screening tool that could
be used by community nurses to assess home environments
and home behavior that may constitute a risk for falls. This
research fills a gap in the nursing literature (Willis, 1998).
The Home-screen was designed to prompt nurses to act
on these risks through referral to specialist services such
as occupational therapy and targeted nursing interventions
to reduce the hazard. These interventions could replicate
or extend nursing falls prevention programs already presented in the literature (Mah, 1996; Ploeg et al., 1994;
Schlapman, 1990; Schoenfeld & Van Why, 1997; Tideiksaar, 1989; Weber, Kehoe, Bakoss, Kiley, & Dzigiel, 1996).
We acknowledge that more comprehensive home hazards
assessment tools exist, in particular the WeHSA (Clemson,
1997), but these tools require specialist professional skill
and considerable time to complete.
This sample of older community-living Australians represent a group of older men and women with high functionality and mainly fair or poor health; a group of older people
susceptible to falls.
The primary aim of this study was to examine the quality
of the instrument through psychometric investigation of
the validity and reliability of Home-screen. The final solu-

Johnson et al.: Home-Screen Scale 175

tion10 items (5 for Home-safe, 5 for Home-behavior)

explained 60% of the concept of home safety and home
safe behavior, confirming adequate construct validity (Hair,
Anderson, Tatham, & Black, 1992). The results revealed
that the 14-item scale was improved if four items were
deleted, and if one item (relating to shoes) was moved
from the Home-safe subscale to the Home-behavior subscale. For the latter, some modification to the item is recommended to allow it to be consistent with the Home-behavior
scale, that is: Person wears shoes at home that fit well
and have good traction on heels and soles.
Construct validity of the instrument was further explored
through examination of differences in known groups using
independence and dependence on transfer as a grouping
variable. This item was selected as ability to transfer has
been previously identified as a risk factor for falls
(McLean & Lord, 1996; Ray et al., 1997), and may also
be considered an indicator of mobility (an important issue
in falls prevention). Veterans who could transfer independently had higher mean scores than those who could not
and this difference was statistically significant, demonstrating that the Home-screen could appropriately differentiate
between the groups.
Internal consistency (a form of reliability) was also explored, and confirmed with alpha coefficients ranging from
0.81 (Home-behavior), and 0.84 (Home-safe), to 0.86 for
Home-screen total scalewell within acceptable levels
(Nunnally, 1978).
The Home-screen was designed to act as a screening
instrument to prompt nurses to reduce falls through attention to well documented extrinsic risk factors of home
environment and home behavior. Consequently, it was important to identify a critical point that reflected a threshold
of risk in relation to these areas. Thresholds of risk
have been identified to be an important dimension of falls
prevention (Wolter & Studenski, 1996). This is important
because the multifactorial nature of falls means that intervention that targets any one area or factor may have limited
effect if it does not lower the overall threshold of fall risk
(Wolter & Studenski, 1996).
An attempt to derive such a point was made based on
the score representing the 25th percentile (71). Findings
from the analyses of veterans Home-screen scores, using
a score of 71 or less (an older person at risk) and those
with a score of more than 71, found an association between
the groups of low and high scorers and frequent and infrequent falling behavior. Here it was apparent that frequent
fallers could be distinguished from others in the sample
on the basis of score (71 or less) on the Home-screen. This
is not surprising, given the role that home environment
and behavior have in fall risk (Connell & Wolfe, 1997).
Similar analyses were undertaken using the same groupings and community nurses perceptions that home modifi-

cation services were required or not required. These

analyses were not statistically significant at the 0.05 level
using a score of 71, but were significant when a score of
74 was used as the splitting point for low and high scorers.
From these preliminary analyses it would seem that there
is support for the statement that a score of 74 or less should
be an indicator to the nurse of a need to seek specialized
services, if available, or to immediately initiate an education program. This threshold score, or critical point, is quite
high. This is not surprising given that the sample live
independently in the community and have high functionality. Consequently, the scale does have a high mean item
score and therefore high overall score, which results in
a high threshold value. Clinically, this high scoring (or
threshold value) is important to note as community nurses,
who can be faced with a wide variety of living conditions
of their clients, need to recognize that a home environment
that is superficially comfortable and acceptable, may hold
safety risks that require attention to detail beyond matters
of cleanliness and comfort.
A short screening tool that assesses home safety and
home safe behavior in community-living older people has
been developed and found to be both valid and reliable.
Previously, the lack of appropriate community nursing tools
in the area was a problem, and may have contributed to
the high number of nurses who did not use an instrument
of any kind to assess this fall risk (Willis, 1998). The Homescreen scale could easily be incorporated in the initial
assessment of a client as it is short, requires no special
training, and relies upon knowledge gained through routine
practice with the client in the home. This instrument could
also be used as a monitoring tool to assess changes in
behavior and the environment following education or home
modification programs.
Further research is required in a number of areas. First,
there is a need to explore predictive validity testing to
confirm that this instrument is predictive of injury and falls
in older people or the examination of specific high risk
subgroups. Second, the development of an administration
manual that would include the provision of structured definitions for key terms such as clutter to assist raters and
ensure increased consistency is required. Third, further
investigation is required into the nature of the items themselves, in particular, the interrater reliability of the overall
scale, subscale, and items. Ultimately, the clinical success
of assessments such as the Home-screen is the ability of
the nurse to use the information to successfully encourage
change by the older persons to make their homes safer.
More research is required to understand why such change
is difficult to achieve (Clemson, Cusick et al., 1999;
Schoenfelder & Van Why, 1997).
Public health nurses have an important role to play in
falls prevention and the use of the Home-screen scale pro-

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Volume 18 Number 3 May/June 2001

vides these nurses with a valuable tool to heighten awareness, frame intervention programs, seek specialized help
where available, and confirm successful actions when enacted. Making the home safe for older people not only
reduces older peoples morbidity and mortality, but also
adds to their quality of life by reducing their fear of falling.
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