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Identification of a nursing issue and the application of a nursing theory
Introduction
Falls among elderly hospital patients is a significant issue that has been widely addressed in research and practice. According to AHRQ (2013), a patient fall is defined as an unplanned descent to the floor with or without injury to the patient (p. 1). Research by Hayakawa et al. (2014) found that the overall incidence of falls in inpatient settings was 3.28 per 100 person-days. However, for the elderly people, this figure can be much higher: age was found to be among the key risk factors for falling along with the previous history of falling, cognitive dysfunction, and wheelchair use (Hayakawa et al., 2014).
In the United States, falls occur nonetheless frequently: AHRQ (2013) reports that between 700,000 and 1,000,000 patients fall in U.S. hospitals each year. Due to the health problems associated with older age, such as osteoporosis, falls pose a serious health risk for elderly hospital patients. Falls can result in injuries, such as fractures, lacerations, or internal bleeding (AHRQ, 2013). Developing an EBP project on this issue could help to determine appropriate measures to prevent hospital falls in the elderly, thus decreasing the risk of injuries, improving patient outcomes, and reducing utilization of care, which in turn can decrease the costs faced by medical institutions (Haines et al., 2013).
Therefore, falling was selected as the focus of the project due to its importance to elderly patient care. The next part of this assignment will comment on the applicability of the EPB project topic to the clinical practice of Nurse Practitioners. This will be followed by a thorough overview of the issue of falls in elderly hospital patients. Finally, the conclusion will define the expected outcomes for the project proposal, summarize the key points offered in this assignment, and provide a self-reflection.
Application
The chosen MSN Program specialty track is Nurse Practitioner. Nurse Practitioners work in clinical settings, which is why issues that are prevalent in inpatient hospitals, including falls in elderly patients, are important to their work. Patients with a higher risk for falls require special attention, as falling can cause unwanted injuries and lead to health complications (AHRQ, 2013).
Moreover, due to the possible consequences of falling, including internal bleedings and fractures, falls in elderly patients can increase care utilization and expand the patients hospital stay. This requires additional resources, including staff, medication, surgeries, and other procedures required to treat the consequences of falling. Nevertheless, the effectiveness of fall prevention efforts remains relatively low due to implementation failures and non-participation (Williams, Szekendi, & Thomas, 2014).
Applying preventive measures correctly and consistently could help to reduce the incidence of falls in inpatient care settings, thus ensuring better patient health outcomes and reducing institution expenditures on prolonged hospital stay and extra procedures (Haines et al., 2013). Moreover, ensuring that hospital rooms are safe and do not pose an increased risk for falling will help institutions to avoid legal issues by adhering to all safety standards. Thus, the focus of the project is important to the chosen specialty track. By examining the effectiveness of possible interventions, this project can help institutions to promote patient safety and reduce the occurrence of falls.
Nursing Issue Discussion
Occurrence and Consequences
The selected nursing issue is elderly patient falls in inpatient hospitals. Hayakawa et al. (2014) studied the overall incidence of falls in an inpatient hospital in Japan, collecting information for 9470 patients. The researchers examined the incidence of falls per 100-person days for four age groups: 50 or under, 50-64, 65-74, and over 75. The study found that the highest incidence of falls in male patients was for the age group 65-74 (Hayakawa et al., 2014).
In female patients, however, the highest occurrence of falls was observed in the below 50 age group (Hayakawa et al., 2014). Out of 9470 patients, 230 had experienced falling during their hospital stay; factors such as the history of falls, wheelchair use, and impaired mobility were found to be associated with a higher risk of falling (Hayakawa et al., 2014). In the United States, falling among adult hospital patients was examined by Bouldin et al. (2013).
Based on a two-year data on 1263 hospitals obtained from the National Database of Nursing Quality Indicators (NDNQI), the researchers state that the rate of falls was 3.56 per 1000 patient days (Bouldin et al., 2013). The researchers have also evaluated the incidence of patient falls by unit type. Medical units were found to have the highest rates of both injurious and non-injurious falls, whereas surgery units had the lowest incidence (Bouldin et al., 2013).
Although an extensive amount of research on inpatient falls is available, not enough studies detailing the possible consequences of falls and their implications for patients and institutions are examined. For instance, Bouldin et al. (2013) state that approximately 25% of falls resulted in an injury; however, the researchers do not provide a detailed insight into the occurrence of different types of injuries and their effect on patient outcomes. Similarly, Miake-Lye, Hempel, Ganz, and Shekelle (2013) review the issue of inpatient falls, stating that 30 to 50 percent of all inpatient falls result injuries.
However, the researchers also mention that Even a fall that does not cause an injury can trigger a fear of falling, anxiety, distress, depression, and reduced physical activity (Miake-Lye et al., 2013, p. 390). Overall, the existing research on the topic of inpatient falls frames the rationale for selecting this nursing issue as the focus of the project: studies show that, whereas the occurrence of falling in inpatient settings is relatively low and can be predicted by risk factors, the possible consequences of falls for patients and medical institutions are serious.
Stakeholders
There are three groups of stakeholders that are affected by inpatient falls. First of all, as falls pose a risk of fractures, lacerations, and other health consequences, they affect patients and their families. Secondly, patient falls affect medical institutions and units, as the need for care and medical procedures grows. Finally, falling affects medical practitioners and nurses, as the number of work increases if patients are not released as planned and have to stay in the hospital for a longer period of time.
Literature Search Strategy
To prepare an evidence-based project on the issue of elderly patient falls in hospitals, it is necessary to address a solid body of existing literature on the prevention of falls. The two particular interventions that will be examined as part of the project are de-cluttering and the use of bed alarms. The search should focus on qualitative and quantitative research studies examining the effects of these interventions on the occurrence of patient falls, published within the past five years.
Online databases, such as SAGE and Science Direct, should be the primary points of search. The articles should be evaluated on their applicability to the topic, as well as the validity and reliability of the results obtained. Accredited medical scholarly journals, such as BMJ, the New England Medical Journal, etc. should be considered the desirable sources of publications. The PICOT question that the project will be focused on is as follows:
In elderly patients at risk for falls (60 to 80 years old), does use bed alarms and eliminating clutter in the room, such as carpets and furniture, produce a significant decrease or elimination of falls during the hospital stay?
Conclusion
Overall, the research evidence gathered as part of the assignment suggests that addressing the issue of falls in elderly patients would help to avoid injuries, reduce the utilization of care, and promote better treatment outcomes. For medical institutions, prevention of falls will also result in reduced care expenditures, as fewer procedures will be required. The main expected outcome of the proposal is the identification of the effectiveness of the proposed interventions.
As such, the project will seek to determine if the use of bed alarms and de-cluttering of hospital rooms will result in the lower occurrence of falls in high-risk elderly patients. As it is possible that the research articles examined as part of the project will address other intervention options, the project can also assist in determining alternative solutions to the issue of elderly patient falls.
Writing this assignment allowed me to increase my understanding of the specified nursing issue. For example, I found evidence-based information on the occurrence of falls, as well as on the possible consequences resulting from them. Moreover, the assignment also helped me to view the issue in a broader context by examining all the stakeholders affected by patient falls. For instance, I found that falling can result in higher care spendings and prolonged hospital stays, thus impacting the profitability of medical institutions and nurses workload. All in all, I believe that this project will help me to improve my knowledge of this nursing issue and the possible prevention techniques that could be used to decrease its occurrence.
Strategies for Preventing Falls in Elderly Patients: Improving Patient Outcomes
PICOT/PICo Question
In elderly patients at risk for fall (60 to 80 years old), does increase supervision and eliminating clutter in the room, such as carpets and furniture, compared with lack of supervision, clutter room, and walkways, produce a significant decrease or elimination of falls in elder patients at risk for falls during hospital stay?
Research Literature Support
Article 1
A study by Hempel et al. (2013) documents the components necessary for implementing the prevention of hospital falls. The authors conducted a comprehensive systematic review of studies and reports of individual strategies. Importantly, both bed alarm installation and decluttering of the environment were identified as important components. However, the data was not disaggregated, which means that the comparative efficiency of either of the components was not determined.
In addition, the authors pointed out that a significant proportion of the reviewed sources lacked the description of adherence strategies and fall prevention measures applied (Hempel et al., 2013). Such a gap confirms the relevance of the project at hand and identifies an important element of the data collection process that should be incorporated for higher fidelity of the results.
Article 2
A quantitative study by Shee, Phillips, Hill, and Dodd (2014) evaluated the feasibility and effectiveness of using bed alarms in reducing the patient falls. The authors conducted a cohort study within a single subacute ward. The findings confirmed that the alarms could be used as feasible and effective strategies. Interestingly, the authors also identified several important limitations of the technology, such as the lack of differentiation between the alarm sounds and regular calls and the non-specific nature of the signal. In many settings, such limitations would contribute to confusion and undermine the overall efficiency of the system (Shee et al., 2014). It should also be pointed out that the evidence of the strategys efficiency is preliminary in nature and need to be confirmed with further research.
Article 3
Ward-Smith, Barrett, Rayson, and Govro (2014) study the feasibility of a software-assisted bed alarm system for the prevention of the possibility of falls in acute care settings. By applying a retrospective chart review to the data derived from medical records of randomly selected patients, the researchers were able to establish higher-than-normal interruptions within a fall correlation.
It is important to note that while the findings establish the effectiveness of alarm-assisted software, the successful use of the obtained predictions for the prevention of falls was not proposed by the authors. In other words, the article contains information that suggests the direction for further research rather than a definitive solution, and while the findings are consistent with the initial assertion, the additional inquiry is necessary before practical applications.
Article 4
The study by de Sousa Costa et al. (2017) evaluated the nursing outcome of Fall Prevention Behavior and its indicators in patients with stroke. The findings indicated statistically significant differences between the groups guided by nurses with and without the use of operational definitions. The indicators chosen for the study included the elimination of clutter from the room and the use of an alarm system, with the former producing greater statistical significance (de Sousa Costa et al., 2017). However, the study was performed within a single region and on a limited number of participants, which limits its generalizability. In addition, the study did not focus on a specific indicator and instead provided an overview of correlations.
Literature and PICOT
The identified sources are linked directly to the PICOT question since they shed light on the ways in which patient falls are currently managed and outline the problems thereof.
Solution
The studies indicate the plausibility of the chosen strategies for addressing the nursing issue. The evidence available in the articles is consistent with the suggestion that the proposed interventions can decrease falls incidence among elderly patients. Thus, the clutter management technique may be viewed as a possible solution (Johnson et al., 2014).
Theoretical Framework and Change Model
Hendersons Need Theory: What Patients Require
Implying that the patient should be assisted yet provided with a significant amount of independence, the Hendersons Needs Model will be especially important in managing the needs of elderly patients, who will require guidance from nurses yet will also demand certain independence in their choice of actions (Peate, Wild, & Nair, 2014). Thus, the passive strategy based on removing clutter as opposed to aggressive instructions concerning the movement trajectories for the target population is bound to have a positive impact as soon as it is supported by the values and concepts of Hendersons model (Arora, 2015).
Kotters Change Management Framework
To promote active change in the environment of the hospital, one will have to consider Kotters model. The identified approach allows for efficient management of the transfer from one framework to another, at the same time making sure that the resistance among the staff members should be reduced to a minimum (Sare & Ogilvie, 2016). The model will imply that eight crucial steps should be taken:
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Creating a series of guidelines for the staff concerning hospital space management;
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Building a comprehensive guide of the nurses;
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Forming the strategic vision based on meeting the needs of the patients successfully and promoting their safety as the ultimate goal;
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Enlisting the volunteers that will support the concept and encourage the rest of the staff to accept it as the best possible framework;
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Enabling the nurses by promoting patient-centered values;
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Generating short-term wins by setting minor objectives (e.g., determining the optimal design for a particular area);
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Sustaining acceleration by stressing the importance of consistent support for patients and supervision thereof;
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Instituting change by introducing the concept of clutter removal as the foundation for a fall prevention framework (Wolf & Hignett, 2015).
Research Approach and Design
Using the Quantitative Method
It is crucial to determine the efficacy of the approach for patient fall management based on removing clutter from the area compared to other approaches to inpatient safety. Therefore, it is necessary to quantify the information retrieved in the course of the research. Thus, a quantitative approach is crucial.
Research Approach: Quasi-Experimental
To make sure that the suggested framework is efficient, one will have to test it by introducing it to the environment of a hospital. However, a full-scale experiment is impossible due to the inability to embrace the entire target population. Therefore, a quasi-experimental design implemented at a local nursing facility will be appropriate.
PICOT Elements: Determining the Focus of the Study
The patients at risk of falls will be introduced to the intervention based on the strategy of removing clutter from the target environment. The approach will be compared to the traditional intervention that does not involve supervision or the removal of clutter. The intervention will be provided throughout the length of the hospital stay.
Design Approach Description: Randomized Controlled Trial (RCT)
An RCT strategy will be used. Particularly, the target population will be split into the control group and the group to which the intervention will be provided. Thus, the efficacy of the strategy will be assessed successfully.
The Rationale for the Design Approach
The reasons for using the RCT framework are quite basic. Particularly, the identified strategy allows for carrying out an efficient comparison between the two groups at the identified time slot. As a result, the evaluation of the intervention can be conducted successfully (Hayden, Smiley, Alexander, Kardong-Edgren, & Jeffries, 2014).
Advantage of the RCT: Detailed Cause-And-Effect Analysis
When considering the benefits of RCT as a tool for conducting a study, one must mention that it allows establishing very strong cause-and-effect links between the variables considered in the research.
Disadvantage of the RCT: Narrow Focus of the Study
Unfortunately, RCT also has its limitations. Since it implies that a study should be carried out with a limited number of participants, it does not allow for a full representation of the target population.
Sampling Method
Target Population: Description
The study will be carried out among elderly patients. Particularly, the people aged 60-80 will be recruited for participating in the research. The inclusion criteria will incorporate the propensity to fall displayed by the research participants. The condition that the target population may have, as well as the severity thereof, will not be considered an essential characteristic and, therefore, will be disregarded. It is expected that different ethnicities will be represented by the target population. Thus, a comprehensive multicultural framework for meeting their needs will be designed.
Probability Sampling: Justification
In the course of the study, a probability sampling technique will be used. Seeing that the probability sampling technique allows for a random selection of the participants, it is expected that it will increase the possibility of retrieving objective data and, therefore, receiving the results that will represent all members of the target population. To be more specific, the identified approach implies that all groups included in the target population have approximately equal opportunities to be selected.
Granted that the issue of fall among elderly patients is defined by a range of factors, some of which are associated with the cultural issues and the efficacy of communication, as well as other culture-specific issues, there are reasons to assume that all elderly people are prone to falls disregarding their cultural specifics (Hempel et al., 2013). Therefore, a simple random sampling strategy as the probability technique that will help represent all target groups successfully will have to be utilized.
Sampling Process Description and the Sample Size
The technique based on random numbers will be used to select the participants that will represent the population sample. The sample size, in turn, will be calculated based on the formula suggested for case control studies: Sample size= (r+1(p*)(1-p*) Z_²+Z_( D2)^2)/(r(p_1-p_2)^2 ) (Charan & Biswas, 2013). According to the authors of the study, the specified formula allows for determining the sample size for the case studies where a group to which a specific intervention is introduced is compared to a control group (Charan & Biswas, 2013).
Advantages of the Sampling Method
When considering the advantages of the identified approach, one must mention the fact that it does not require a deep understanding of the specifics of the groups which the target population represents. As a result, the participants of the study are viewed as homogenous, and the outcomes of the research are interpreted as general. Consequently, the prerequisites for building a comprehensive framework that will help address the needs of any population are created (Hirose et al., 2015).
Disadvantage of the Sampling Method
However, the specified approach also has its problems. For instance, larger errors can be observed in the studies that deploy the identified framework as opposed to other types of sampling. Furthermore, the tool cannot be used in the environments where the population can be characterized as naturally heterogeneous. Nevertheless, it is expected that the random sampling technique will help deliver the results that will promote the further development of a fall prevention strategy.
Participants Protection: Password Protection
To make sure that the personal data of the participants should remain safe and should not be disclosed to a third party, one will have to consider using password-protected databases.
Data Collection Process
Seeing that the research data will have to be quantified, it will be reasonable to consider analyzing the information retrieved from incident reports. The latter will provide not only exhaustive data about the number of falls that have occurred at a certain time slot but also the circumstances that contribute to the occurrence thereof. Particularly, the external and internal factors will be mentioned, thus, providing the foundation for determining the strategies that will help avoid the incidences of falls successfully (Taylor, Bogdan, & DeVault, 2015).
The answers to the questionnaires dispersed among the nursing staff will also shed light on the nature of falls and the frequency of their occurrence in the hospital setting. Therefore, questionnaires and report analysis will have to be viewed as the key sources of the required data.
Data Collection Points
The information that will have to be collected for the research will need to be gathered in a manner as subtle and natural as possible so that the essential nursing processes occurring in the target setting should not be disrupted. Therefore, it is suggested that the questionnaires should be provided to the nurses twice throughout the length of the study, i.e., at the beginning of the quasi-experiment and the end thereof (Taylor, Bogdan, & DeVault, 2015). The information from the reports will be collected on a daily basis so that the latest data about the incidences of falls in the target setting could be received.
Length of Time
The application of the new intervention that will allow for a drop in the instances of falls among the elderly patients will require substantial time. Therefore, it is reasonable to suggest that the study will take approximately a month. In other words, the process of data collection will take a total of 30 days, with a detailed analysis of the reports submitted by the nursing staff. It is expected that, by the end of the month, the promotion of the new approach based on the elimination of clutter in the hospital setting will have its effects on the fall statistics among the patients.
Source of Data
As stressed above, reports and questionnaires will serve as the main source of the necessary information. It will be crucial to make sure that every incidence of a fall should be documented properly by the nursing staff. Thus, providing the nurses with detailed guidelines about the intervention and the data management process will be essential to the outcomes of the research. The questionnaires, in turn, will also point to the possible factors that may have been overlooked in the process of meeting the needs of the target population and, therefore, affecting the fall statistics (Cleary, Horsfall, & Hayter, 2014).
Furthermore, the falls that may have been undocumented for one reason or another will be identified successfully with the help of questionnaires and, therefore, taken into account when carrying out the data analysis.
Data Quality
It is expected that the information obtained from the identified sources will be of rather high quality. Because of the rigid standards deployed at nursing facilities, reports submitted on a daily basis showcase the issues faced by patients in a quite clear and efficient manner. As a result, a detailed overview of the fall statistics among the elderly residents of the target facility will become possible. Furthermore, the significance of workplace honesty and responsibility will have to be fostered among nurses so that the incidences of falls should not be concealed from the researchers (Cleary, Horsfall, & Hayter, 2014). Thus, apart from increasing the quality of the data, one will be able to promote integrity among the staff, consequently, triggering a rise in the quality of the nursing services.
Analysis
Data Analysis Explanation
In order to carry out a detailed analysis of the information retrieved from the reports and questionnaires, one will have to consider using both descriptive and bivariate statistics. Thus, the foundation for an in-depth assessment of the suggested framework can be built. The suggested approach to data analysis will also help promote more accurate processing of the information (Setia, 2017). Consequently, the research results will help build the foundation of a very efficient strategy for managing and preventing the instances of falls among elderly patients.
Descriptive Statistics: Central Tendency
The focus on the central tendency among the target population ill shed light on the urgency of the problem as a whole. By identifying the mean and the median of the number of falls among the elderly patients of the hospital, one will be able to determine the severity of the issue, as well as determine possible improvements in the patient statistics after the implementation of the proposed intervention (Setia, 2017). Therefore, the use of the central tendency as the primary means of locating the current trends among the elderly patients must be considered a necessary addition to the analysis.
Bivariate Statistics: T-Tests
However, to determine the actual efficacy of the strategy based on the removal of clutter and the reorganization of the hospital space, one must consider using Students t-test as the key analysis tool. The identified test will help determine whether there is a connection between the application of the approach based on clutter removal and the change in the incidences of falls among the hospital patients. The further analysis of the data sets that will be formed after the essential information is collected will provide the foundation for proving the initial hypothesis either right or wrong (Setia, 2017). Therefore, a t-test must be considered the next step in the analysis of the study data and the identification of the research results.
Conclusion
Summary: Key Points and Their Interpretation
The incidences of falls among inpatients remain dangerously frequent, thus, affecting the recovery rates among elderly patients and impeding their recovery. Furthermore, falls may contribute to not only a prolonged hospital stay but also the development of additional severe health issues. Therefore, it is crucial that a strategy based on the reconsideration of the hospital space and the removal of clutter should be viewed as a possible intervention. It is expected that the identified approach will serve as the foundation for a rapid increase in the number of positive patient outcomes.
Self-Reflection: What Has Been Learned
An overview of the problems associated with falls among elderly inpatients has shown that patient outcomes are affected greatly by not only the factors related to global and deadly diseases such as Alzheimers but also much more basic and simple factors that can easily be avoided. The observed lack of initiative when it comes to preventing the instances of patient falls shows that there is a need to redesign not only the current approach to managing falls but also the very focus of the nursing services and ethics, making them patient-centered. As a result, a gradual improvement in patient outcomes can be expected.
Evaluation Plan and Translation of Results
Evaluation Plan
In order to ensure the adequate level of quality throughout the intervention and determine the success of the entire project, it would be necessary to develop and implement a consistent evaluation process. Such process should consist of two components, a comprehensive examination of the outcomes based on the information derived from the gathered statistical data and a flexible ongoing assessment of the process and the available performance indicators.
The data necessary for determining the success of the intervention will be gathered from the clinical reports that document the falls occurring in the identified sample. In addition to the occurrence of falls, the information on the circumstances of each event will be included in the dataset. Such approach would provide a detailed image of the common causes of the falls and, by extension, the relevance and efficiency of the chosen intervention.
In addition, the data will be complemented with the results of the questionnaires administered to the nursing practitioners participating in the project at the onset of the experiment as well as after its termination. The data retrieved from the questionnaire would enhance the understanding of the causes of the falls and possibly introduce the insights into the factors overlooked in the research design. The data from the reports will be collected daily in order to observe the dynamics of change and introduce minor adjustments to the process if necessary.
Once the collected data is processed, it should be communicated to the stakeholders. Since the results of the quantitative analysis are expected to be challenging for understanding for most of the stakeholders (with the exception of the research community), it would be reasonable to convert them into an accessible and concise format. Thus, the key indicators such as the incidence of falls, the most significant causes, and the identified positive relationship between the intervention and the improvement of the outcomes will be converted into charts and graphs that could be delivered to the NPs on site, the administrators of the target institution, and the community health organizations.
In this way, the necessary clarity of communication will be maintained, and the transparency of the results will be ensured. In other words, the visual representation of the findings will be sufficient for the decision-making throughout the project and to arrive at the conclusions regarding its success after the projects termination.
It is also important to establish the o
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