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Introduction
Falls in-home care is one of the major causes of further complications, especially in older adults. By the very definition, home care implies that nurses and family caregivers provide assisting services to patients. The daily tasks that require help are composed of transfers from a bed to a wheelchair in a home environment. The problem of falls is largely associated with a lack of proper training of nurses who fail to recognize and address risk factors.
This paper will propose the study of using a systemic nursing education to reduce the risk and incidence of falls. The PICOT question will be formulated, and the theoretical framework will be determined to create a basis for the proposed study that will use the method of the critical literature review. The purpose of this literature review is to study the state of the art research related to fall prevention in the elderly population receiving home health care.
Significance of the Practice Problem
The problem of falls affects people aged 65 and over, especially those who have to take medications that impact mobility, pain levels, and coordination. As reported by the Centers for Disease Control and Prevention (CDC), 1 out of 3 older adults living in the community falls each year, which results in seven million traumas in the US (Powell-Cope, Thomason, Bulat, Pippins, & Young, 2018). These numbers demonstrate that the problem is critical, and it will deteriorate due to the aging of the population.
The cost of not fixing the problem refers to the complications encountered by patients after falls, such as pain, serious injury, and death. Today, the average cost of hospitalization because of a fall injury is $34,294, while the annual medical costs are totaled at more than $50 billion (Cooper, 2017). Home care falls are likely to increase the financial burden of both patients and healthcare in general.
It is important to explore the identified problem to find an effective solution to preventing falls, which will increase patients’ quality of life and enhance safety. The families also receive additional anxiety due to the increased needs of their relatives. The society is affected by the necessity to create new healthcare policies and legal decisions to help patients who fall in recovering and handling economic and functional issues (Milos et al., 2014).
Considering that home care conditions require more effort and time to be spent for patients, the financial and ethical burden becomes even more evident. The review will contribute to the problem solution by designing a strong theoretical basis for conducting further studies and formulating valuable strategies since information about what should be done to improve the situation and what assessing tools to use is lacking.
PICOT Question
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P – Adults aged 65 and over;
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I – Systematic nursing training targeting the recognition of risk factors;
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C – No specific education;
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O – Improved fall prevention measured by lower incidence levels;
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T – 1 year.
A PICOT question: In patients aged 65 and over, how does systematic nursing training targeting the recognition of risk factors compared to no specific education affect fall prevention measured by lower incidence levels within 1 year?
The following objectives are identified: provide teaching for patients, caregivers, and providers on how to handle daily needs and recognize fall risks; the use of assistive devices such as wheelchairs, canes, and walkers to compensate coordination; and the identification of risks to reduce the threat of falls.
Theoretical Framework
The Model for Improvement developed by Deming, a non-nursing theorist, will be utilized as the goal is to evaluate the potential enhancement of nursing practice in promoting better fall prevention. Ida Jean Orlando and her nursing process theory may be noted due to its similarity with the Model for Improvement (Coury et al., 2017). As stated by Crowl, Sharma, Sorge, and Sorensen (2015) and Crowl et al. (2015), the Plan-Do-Study-Act cycle is useful to analyze the situation and prepare for the intervention implementation. In particular, the current needs should be accessed, documented, the problem should be studied in detail, and conclusions should be made to provide recommendations.
Synthesis of the Literature
Older people make up a significant part of the population, and their numbers are increasing. One of the studies researched the prevalence of falls and found that every third elderly person falls at least once a year, which leads to fractures at home, and there is a need to improve the situation (Powell-Cope et al., 2018). No recommendations are identified by Powell-Cope et al. (2018) in their study. Based on the study of fall risks, Pfortmueller et al. (2014) state that among the common causes of falls, there are dangerous places in the house, sarcopenia, decrease instability and balance, blurred vision and/or hearing, as well as side effects of medication. Half of the cases occur at home, especially in the toilet, bathroom, and bedroom.
Therefore, home nurses about the possibility of falling should always warn relatives. With aging, the risk of falls and, consequently, injuries grows, as stated by Bekkema et al. (2014) and Liebel, Powers, and Hauenstein (2015). These two studies examined falls in older adults with disabilities and found that special training is needed for nurses who care about geriatric patients, while the recommendation is to attract external specialists to provide consultations for nurses.
Education of patients and nurses is regarded as one of the key areas in addressing falls in older adults. McKenzie et al. (2017) concern that there is a gap between geriatrics-trained health care experts and the needs of older adults, which can be addressed by training of the interprofessional teams based on community-based practice. If the medical staff knows about the patient’s susceptibility to falls, they can be avoided.
In their turn, Godlock, Christiansen, and Feider (2016) conclude that the evidence-based team of care providers significantly decreased patient falls in their study (from 1.90 to 0.69 falls per 1,000 occupied bed days) (p. 21). The implications are that nurses may prevent falls by promoting adequate physical activity, creating a safe environment, and taking other necessary steps. Goldsack, Bergey, Mascioli, and Cunningham (2015) explore hourly rounding and conclude that strong leadership and Six Sigma strategy are likely to engage more professionals in care. Therefore, they mention that it can be used to reduce falls in in-patient care units, yet it is not pertinent to home care.
The scholarly literature presents a wide range of studies that explore, design, and assess the interventions that can be used by nurses to reduce home care falls at-home care. Home-based management is the core of preventing falls, as discussed by Möller, Kristensson, Midlöv, Ekdahl, and Jakobsson (2014). The authors evaluated the mentioned intervention in one year and discovered that it was not effective to decrease falls since the participants of both groups showed insignificant changes. Sherrington et al. (2014) found that an individualized home exercise prescription increased falls even though it also improved the mobility of patients report similar results. Both studies provide no specific recommendations, yet they identify the needs for further research.
Another similar trend noted by several studies is that many patients, about 80 percent, fall without witnesses, which deprives them of quick help (Kua et al., 2017). One of the proposed studies aims at investigating the team-care deprescribing process, hypothesizing that it is an effective measure to combat patient falls (Kua et al., 2017). Jeon, Jeong, Petrofsky, Lee, and Yim (2014) assess women living in rural areas who were at a high risk of falls and received recurrent fall prevention programs.
The randomized-controlled trial methodology reveals significant differences between the intervention and control groups in such points as dynamic balance, ankle heel-rise test, and other related aspects. It is recommended that the fall prevention program should be applied in practice as it is beneficial in enhancing patients’ balance and muscle strength. Among other issues, it should be stressed that this is the only study that evaluates the situation with falls in older adults living in rural areas.
Preventing falls is important because it can contribute to lower mortality and morbidity. Cooper (2017) states that the model for improvement and communication are fundamentally based on the study results that show that falls reduced more than twice. According to the findings obtained, the above author suggests that the very care process should be designed in a manner that promotes continuous enhancement.
The study by Carande-Kulis, Stevens, Florence, Beattie, and Arias, (2015) who explored the Otago Exercise, Tai chi: Moving for Better Balance, and Stepping on programs on the prevention of falls identifies that the last of them was the most effective in terms of cost-benefit analysis ($529.86 and an ROI of 509%) (p. 77). Accordingly, the authors suggest that funders should consider their findings in selecting one or another program for older adults.
Another research performed by Kirkpatrick, Boblin, Ireland, and Robertson (2014), focuses on the Promoting Action Research in Health Services framework, within which nurses are expected to encourage patients to self-care. Based on the integration of nursing knowledge in a patient’s background, these authors recommend explaining to students the complexity of care and the importance of organizational initiatives.
An important role (30% reduction in falls) of the Chaos Falls Clinic is emphasized by Palvanen et al. (2014) who use a randomized controlled trial and assume that it should be applied by care organizations. The primary implication of the results received by the authors refers to the utilization of the specified program by adjusting it to specific care settings. The evidence shows that there a lot of articles that focus on clinical care as the context of preventing falls, which points to the need to conduct more research regarding home health interventions. In other words, it is still unclear how nurses may effectively address the given problem due to the limited information and evidence-based strategies.
There is an increasing amount of data on programs conducted for the care of the elderly homebound patients. Among them, balance training and improvement of environmental conditions occupy the central place. According to Ganz et al. (2015), the program called Assessing Care of Vulnerable Elders Practice Redesign for Improved Medical Care for Elders was proved to be unsuccessful even though care was improved. It seems to be essential to stress the fact that it is suggested that higher-intensity interventions should compose future research. Also, appropriate staff training leads to a positive effect only in combination with other activities.
Speaking of the differences that can be identified in the literature, one may note that little is known about specific programs. In their turn, Spiva et al. (2014) consider that team training is likely to lead to a 60 percent reduction of falls in older adults. They focus on interactive cognitive-motor training and conclude that it may significantly improve the current situation. It becomes clear that there is a need to examine the target topic in an in-depth manner to contribute to both theory and practice. In particular, Spiva et al. (2014) discuss the benefits of team training as an integral part of preparing health care professionals to cope with the problems of older adults related to the risk of falls. As a result, they recommend adopting team training in various care conditions, including home care.
The attitudes of older adults towards applying technology mean to support their daily activity need to be improved, as stated by Hawley-Hague, Boulton, Hall, Pfeiffer, and Todd (2014). According to the identified authors, 76 academic papers discuss technology about fall prevention, yet the literature about its implementation is limited. Therefore, Hawley-Hague et al. (2014) assume that older adults should be explained of technology benefits relevant to their individual needs.
In their turn, Gell, Wallace, Lacroix, Mroz, and Patel (2015) claim that the use of mobile devices is not associated with the increased number of falls. Instead, their use promotes a greater quality of life for such patients. While the majority of the articles point to similar features, the main controversy is associated with the fact that there is insufficient attention paid to the role of staff training. Fossey et al. (2014) identify the gap existing between the theory and practice, arguing that often nurses use person-centered interventions that are not evidence-based. In this connection, they call for designing clear clinical practice guidelines.
Practice Recommendations
In the view of the above literature review, it is possible to claim that nurse training is a promising intervention that is likely to positively impact older adult patients who are at a high risk of falls. In an in-home environment that is not equipped according to the needs of such patients, nurses must assess potential risk factors. The body of the evidence, namely, its quantity and consistency, suggests that specific education is likely to minimize the number of falls since nurses will eliminate risk factors once they learn to recognize them (Figure 1).
Project Description
The literature review is a paper that integrates theoretical contributions and existing knowledge regarding the given topic. For the proposed study, 30 scholarly articles published within the last five years will be used to ensure the relevance and reliability of the evidence. The official websites of the global and local health organizations such as CDC and others will also be accessed. The following keywords are selected: home care falls, fall prevention, older adult falls, and nurse training programs.
The access to digital libraries will facilitate the research, while the need to synthesize a lot of data will be a barrier. My role in the project is collecting and analyzing data to answer the PICOT question. The study results will be protected within five years and then destroyed in terms of confidentiality. The key nursing benefit from conducting this literature review is the provision of important insights into the falls of older adults in-home care settings. The community may benefit from decreased costs due to prevented falls. My advantage is associated with my great interest in this topic as I have older adults in my family.
Project Evaluation Results
The project will be assessed based on the influence of the described intervention on the target population. Tables A and B will be used, the summative criteria will include the comparison of fall incidence before and after the intervention, and formative criteria will be monitoring of changes in the course of the review, which will ensure validity and reliability. Table A will briefly describe the primary evidence, including key findings, research design, theoretical basis, implications, and the level of evidence.
In its turn, Table B will present the summary of systematic reviews that will be used, focusing on the key question, search strategies, data analysis, inclusion/exclusion criteria, and so on. The interval data will be collected, the extraneous variables will be controlled by noting them in the study, and no statistical data will be used.
Discussion and Implications for Nursing and Healthcare
The conclusions regarding the appropriateness of the mentioned intervention will be made as a result of the proposed study, including limitations, biases, and validity issues. The potential implications will be determined about nursing practice, and recommendations will be provided to make sure that the situation will patient falls will improve. It is expected to provide recommendations on how exactly nurses should identify the risks of falls in older adults and what are the strategies to be applied to address them (Kwan & Straus, 2014). Most importantly, the training needs of nurses would be clarified to use them in the process of preparing educational sessions. Future research needs will be specified in terms of the given problem and potential replication of the study.
Plans for Dissemination
The results of the proposed study will be disseminated to nurses of the health organization I work for. A nurse manager will be given the outcomes to gather the meeting and share the results. At the same time, it should be stressed that a brief version of the research may be published on the related websites that discuss the problem of fall prevention in older adults. I plan to present the findings of the proposed study at a conference on the state level. In my opinion, it would contribute to the overall understanding of the given topic and its further research.
Summary and Conclusion
This paper was aimed at proposing a future study on fall prevention in homebound older adults based on such intervention as a systematic nurse training program. The proposal was successfully created, including the significance of the topic, a brief literature review, and the theoretical framework. Ultimately, plans on project outcomes, implications, and dissemination were included as well. It was suggested that the described intervention would be effective in addressing the target health problem.
References
Bekkema, N., de Veer, A. J., Albers, G., Hertogh, C. M., Onwuteaka-Philipsen, B. D., & Francke, A. L. (2014). Training needs of nurses and social workers in the end-of-life care for people with intellectual disabilities: A national survey. Nurse Education Today, 34(4), 494-500.
Carande-Kulis, V., Stevens, J. A., Florence, C. S., Beattie, B. L., & Arias, I. (2015). A cost–benefit analysis of three older adult fall prevention interventions. Journal of Safety Research, 52, 65-70.
Cooper, R. (2017). Reducing falls in a care home. BMJ Open Quality, 6(1), 1-7.
Coury, J., Schneider, J. L., Rivelli, J. S., Petrik, A. F., Seibel, E., D’Agostini, B.,… Coronado, G. D. (2017). Applying the Plan-Do-Study-Act (PDSA) approach to a large pragmatic study involving safety net clinics. BMC Health Services Research, 17(1), 411-421.
Crowl, A., Sharma, A., Sorge, L., & Sorensen, T. (2015). Accelerating quality improvement within your organization: Applying the model for improvement. Journal of the American Pharmacists Association, 55(4), 364-376.
Fossey, J., Masson, S., Stafford, J., Lawrence, V., Corbett, A., & Ballard, C. (2014). The disconnect between evidence and practice: A systematic review of person‐centred interventions and training manuals for care home staff working with people with dementia. International Journal of Geriatric Psychiatry, 29(8), 797-807.
Ganz, D. A., Kim, S. B., Zingmond, D. S., Ramirez, K. D., Roth, C. P., Jennings, L. A.,… Reuben, D. B. (2015). Effect of a falls quality improvement program on serious fall‐related injuries. Journal of the American Geriatrics Society, 63(1), 63-70.
Gell, N. M., Wallace, R. B., Lacroix, A. Z., Mroz, T. M., & Patel, K. V. (2015). Mobility device use in older adults and incidence of falls and worry about falling: Findings from the 2011–2012 national health and aging trends study. Journal of the American Geriatrics Society, 63(5), 853-859.
Godlock, G., Christiansen, M., &Feider, L. (2016). Implementation of an evidence-based patient safety team to prevent falls in inpatient medical units. MedSurg Nursing, 25(1), 17-23.
Goldsack, J., Bergey, M., Mascioli, S., & Cunningham, J. (2015). Hourly rounding and patient falls: What factors boost success? Nursing2018, 45(2), 25-30.
Hawley-Hague, H., Boulton, E., Hall, A., Pfeiffer, K., & Todd, C. (2014). Older adults’ perceptions of technologies aimed at falls prevention, detection or monitoring: A systematic review. International Journal of Medical Informatics, 83(6), 416-426.
Jeon, M. Y., Jeong, H., Petrofsky, J., Lee, H., &Yim, J. (2014). Effects of a randomized controlled recurrent fall prevention program on risk factors for falls in frail elderly living at home in rural communities. Medical Science Monitor: International Medical Journal of Experimental and Clinical Research, 20, 2283-2291.
Kirkpatrick, H., Boblin, S., Ireland, S., & Robertson, K. (2014). The nurse as bricoleur in falls prevention: Learning from a case study of the implementation of fall prevention best practices. Worldviews on Evidence‐Based Nursing, 11(2), 118-125.
Kua, C. H., Yeo, C. Y. Y., Char, C. W. T., Tan, C. W. Y., Tan, P. C., Mak, V. S.,… Leong, I. Y. O. (2017). Nursing home team-care deprescribing study: A stepped-wedge randomised controlled trial protocol. BMJ Open, 7(5), 1-6.
Kwan, E., & Straus, S. E. (2014). Assessment and management of falls in older people. CMAJ, 186(16), 610-621.
Liebel, D. V., Powers, B. A., & Hauenstein, E. J. (2015). Home health care nurse interactions with homebound geriatric patients with depression and disability. Research in Gerontological Nursing, 8(3), 130-139.
McKenzie, G., Lasater, K., Delander, G. E., Neal, M. B., Morgove, M., &Eckstrom, E. (2017). Falls prevention education: Interprofessional training to enhance collaborative practice. Gerontology & Geriatrics Education, 38(2), 232-243.
Milos, V., Bondesson, Å., Magnusson, M., Jakobsson, U., Westerlund, T., & Midlöv, P. (2014). Fall risk-increasing drugs and falls: A cross-sectional study among elderly patients in primary care. BMC Geriatrics, 14(1), 40-47.
Möller, U. O., Kristensson, J., Midlöv, P., Ekdahl, C., &Jakobsson, U. (2014). Effects of a one-year home-based case management intervention on falls in older people: A randomized controlled trial. Journal of Aging and Physical Activity, 22(4), 457-464.
Palvanen, M., Kannus, P., Piirtola, M., Niemi, S., Parkkari, J., & Järvinen, M. (2014). Effectiveness of the Chaos Falls Clinic in preventing falls and injuries of home-dwelling older adults: A randomized controlled trial. Injury, 45(1), 265-271.
Pfortmueller, C. A., Lindner, G., & Exadaktylos, A. K. (2014). Reducing fall risk in the elderly: Risk factors and fall prevention, a systematic review. Minerva Medica, 105(4), 275-81.
Powell-Cope, G., Thomason, S., Bulat, T., Pippins, K. M., & Young, H. M. (2018). Preventing falls and fall-related injuries at home. The American Journal of Nursing, 118(1), 58-61.
Sherrington, C., Lord, S. R., Vogler, C. M., Close, J. C., Howard, K., Dean, C. M.,… Barraclough, E. (2014). A post-hospital home exercise program improved mobility but increased falls in older people: A randomized controlled trial. PloS One, 9(9), 1-12.
Spiva, L., Robertson, B., Delk, M. L., Patrick, S., Kimrey, M. M., Green, B., & Gallagher, E. (2014). Effectiveness of team training on fall prevention. Journal of Nursing Care Quality, 29(2), 164-173.
Appendix A
Summary of Primary Research Evidence
Legend:
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Level I: systematic reviews or meta-analysis.
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Level II: well-designed Randomized Controlled Trial (RCT).
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Level III: well-designed controlled trials without randomization, quasi-experimental.
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Level IV: well-designed case-control and cohort studies.
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Level V: systematic reviews of descriptive and qualitative studies.
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Level VI: single descriptive or qualitative study.
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Level VII: opinion of authorities and/or reports of expert committees.
Appendix B
Summary of Systematic Reviews (SR)
Legend:
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Level I: systematic reviews or meta-analysis.
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Level II: well-designed Randomized Controlled Trial (RCT).
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Level III: well-designed controlled trials without randomization, quasi-experimental.
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Level IV: well-designed case-control and cohort studies.
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Level V: systematic reviews of descriptive and qualitative studies.
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Level VI: single descriptive or qualitative study.
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Level VII: opinion of authorities and/or reports of expert committees.
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