Evidence Based Practice of Nursing_An exploration of an aspect of evidence based practice that is relevant to my own professional practice

Evidence Based Practice of Nursing

An exploration of an aspect of evidence based practice that is relevant to my own professional practice

 

Introduction

            As people grow older, they increasingly experience age-related changes, diseases and disorders. Such conditions have profound impact on older people’s ability to balance. They become more prone and at risk of falling. The rate of falling in Hong Kong had an immense growth over the years particularly within hospitals. In fact, patient fall is the third of main ward incidents in the hospital I currently worked for as reported from the risk management team of the cluster. As such fall is one of the most significant risks for old patient in the emergency department. Terrell et al (2009) also noted that are the most common adverse events reported in the hospitals and ED is increasingly becoming common. Knowing this, observation room staff may complete a fall assessment to see whether an old patient is at risk of falling. Discussing strategies with ward staff and risk management committees would be then plausible especially that the main goal here is to reduce the chances of the old patients toward having a fall in the observation room. This paper will focus on the situation regarding falls and falls prevention in A&E in light of my practice.

Clinical decision

            Falls among elderly inpatients represent a major care concern for hospital institutions. In my area of practice I have learned that there is a prevalence of falls among inpatient older people. Various accounts that I have encountered include walking in the aisle with this old male patient who is refusing the guidance of a nursing assistant, getting pissed off with the assistant, walking way to the comfort rooms even inside their respective rooms and the worst are always inside the A&E wherein old patients are being outbalanced then falling right on the ground. At times, these things happen both in and without the presence of nursing assistants, nurses and doctors. It would be tolerable if these people are around when older patients had near misses and slips who could immediately offer help but it would not be acceptable if older patients are not given the proper venue to determine their levels of risk. As falls are generally resultant from interactions of various risk factors (Tweedy, 2005), I therefore decided the need to discuss with ward staff and risk management committees the necessity of a falls prevention programme that could effectively reduce the rate of fall among the elderlies admitted in A&E. Identifying those who are at high risk of falling would be a significant step in providing older patients the quality of health life that is being jeopardized by mere falling.

Revised cognitive continuum

            Given the prevalence of falls, the long-term consequences and the costs of fall-related injuries had become a burden not just to the hospital and the medical professional staff but also to the patients’ families, friends and relatives and also to the other inpatients who are afraid and threatened to experience the same. There are risks that could be addressed and hence corrected. The main objective of this clinical decision is to minimize the risks of failing by means of implementing a risk assessment specifically since a broader evidence base is necessary for sound nursing judgments and decision-making (Standing, 2008). Such a strategy of risk reduction leading to falls prevention puts emphasis multidisciplinary working, reflecting the multi-factorial and complex nature of falls (The Chartered Society of Physiotherapy, 2001, p. 4). A UK report submitted by Health Evidence Network (HEN) discerns that a fall may be a first indication of an undetected illness. To wit, through risk assessment co-morbidities of patients could be determined not to mention that the outcomes of falling would be prevented. It would be necessary to take note inhere that falls can result in different unfavorable outcomes such as minor bruises, fractures, disability, dependence and even death.

Further, the main reason why older adults are hospitalized is due to fall-related injuries, five times more often compared to other causes for hospitalization as well. Falls had been the leading cause of injury deaths among people of 65 and over years of age and half occur in their own homes while others in various places such as parks, train stations and movie houses. Because the hospital administration is evidently taking an initiative to promote and improve the beneficial health outcomes of patients including the inpatient older people, the hospital is attempting to tap its ethical responsibility not just to the patients and their respective families but also to the public in general, a ethical dimension of revised cognitive continuum (Standing, 2008). Furthermore, this clinical decision involves not just a single discipline but is taken from a holistic view to include whole hospital community with ward staff and risk management personnel as the key players. In this way, evaluative competence (Standing, 2008) of the hospital community will get to participate and put their inputs hence build up their experiences.

Standing (2008) concluded that “revised cognitive continuum promotes awareness of the nature and the variety of patient-centered judgment tasks and decisions in nursing, how to select the most suitable intervention tactic from available options, and the fallibility of all forms of human judgment from intuitive or experiential to analytic or rational.” In broader context, this clinical decision would be a relevant input towards effective hazard surveillance for physical hazards that could be inexistence in the hospitals, specifically in the observation room of the accident and emergency department. Apart from putting special emphasis on high risk areas, the incidents of fall could be analyzed to determine trends wherein future strategies of prevention would be built. Fall incident investigation could be established and the documentation procedures could be highlighted. Risk of falling would be well-understood in a fashion that it will be collective and a proactive effort as opposed to being reactive which is what is currently happening within the hospital, leading to effective, long-term intervention.     

 

The question now is – Is fall risk assessment useful to minimize the fall risk in the observation room of emergency department? It is necessary then to reduce older people’s risk of falling and the consequent injuries of such fall occurrences for community-dwelling older people. The complex interaction between intrinsic and extrinsic risk factors led to the occurrence of most falls, as suggested by different literatures. There are over 400 risk factors for falling that have been reported (The Chartered Society of Physiotherapy, 2001, p. 6). The intrinsic risks factors that are identified by HEN include history of falls, age, gender, ethnicity, medicines, medical conditions, impaired mobility and gait, sedentary behavior, psychological status, nutritional deficiencies, impaired cognition, visual impairments and foot problems. The extrinsic risk factors are the environmental hazards like poor lighting, slippery floors and uneven surfaces among several others; footwear and clothing and inappropriate walking aids or assistive devices. HEN maintained the third risk factor which is exposure to the elements of risk (Todd and Skelton, 2004). We should understand that falling among older adults is associated with common risk factors that include muscle weakness, history of falls, gait deficit, balance deficit, use of assistive device, visual deficit, arthritis, impaired activities of daily living, depression, cognitive impairment and age, all of which are exacerbated by the quality of the environment they are in, whether environment is conducive for the elderly and that physical hazards are consistently removed when there are such.  

The first journal article that supports the necessity of implementing a falls risk assessment in A&E is that of Davison et al (2005). This research aims to determine the effectiveness of a multifactorial intervention to prevent falls in cognitively intact older persons with recurrent falls. Through a randomized controlled trial of multifactorial post-fall assessment and intervention compared with conventional care, the authors was able to come up with the primary outcome which was the number of falls and fallers and the secondary outcomes included injury rates, fall-related hospital admissions, mortality and fear of falling. There are at least two themes that emerged in the research paper: falling among community-dwelling people is a significant cause for admission in the hospitals and when they are admitted, recurrent falling would be experienced. As such, one would easily understand that risks involved in falling could be innate with that individual who suffers from episodic falling. According to the authors, fall prevention could be effectively implemented through a multifactorial risk assessment and management programme, or individualized, home-based exercise. Nevertheless, in the case of falls occurrences in A&E department, this requires a new intervention because the focus of the authors is preventing falls especially when patients are released from the hospitals.     

Suggestions for falls preventions first appeared in remedial literatures in 1980s. Since then there had been numerous effort to gather evidences to support falls prevention initiatives in medical, rehabilitation and public health. The evidences purport a possible prevention of fall in some populations but for injurious falls, it is yet to be proven. The general effectiveness of fall prevention strategies is connected to the functional status of older people. The first identified group is the healthy older people, though researches showed that reducing falls in healthy older people are ineffective (Gillespie, et al, 2001). Frail older people are identified as the high risk groups including the significantly disabled and patients with acute and neurological illness (The Chartered Society of Physiotherapy, p. 11). It is noteworthy to say that reducing risks factors does not necessarily mean reduction in falls and falls-related injuries. Though it is logical to assume this way, most intervention programmes regarding falls prevention provide only but limited success. The most practical fall prevention programmes for these identified risk groups include multi-factorial fall prevention programmes and exercise only.

The diversity in older people involves distinctions in the level and nature of ageing, their attitude and behavior concerning aging, their willingness and struggle to adapt to the process of aging and their outlook about care are some of this. This condition points to another premise which is there are specific needs for specific sets of people (Miller, 2006). This also implicates the role played by the staff nurses and risk management team and the probable role of education as a two-way process in essence. Since treatments and processes are highly-individualistic, doctors, nurses and carers must posses an array of educational and behavioral interferences. It is necessary then to educate them fully so that they can educate their patients. All staff must be involved in the process; hence, working as a health care team. Educating them must not focus on providing them awareness of who are at risk at falling or the very nature of falling but instead on how they can build personal knowledge based on what they observe in their practice. These could be an effective way to put ‘effective’ in different falls prevention educations.

Gray-Miceli (2007) makes use of the Hendrich II Fall Risk Model in assessing ‘why’ a fall would be experienced in the A&E, as coupled with the post-fall assessment. The author confirmed that the rate of falling increases proportionally with the increased number of pre-existing conditions and risk factors. As such, falls assessment is a useful guideline for practitioners, stating that fall risk-assessment and post-fall assessment are two interrelated but distinct approaches to fall evaluation. In A&E, a best practice approach could be the use of the Hendrich II Fall Risk Model that provides a determination of risk for falling based on gender, mental and emotional status, symptoms of dizziness and known categories of medications increasing risk. This is the strength of the model which includes its brevity, inclusion of “risky” medication categories and focus on interventions for specific areas of risk rather than on a single, summed general risk score. Indeed, another strength of the model is the inherence of informations leading to interventions. With the targeted interventions, the model could also tap into the role of caregivers specifically in modifying and/or reducing specific risk factors present.   

Therefore, staff nurses, interns and other medical practitioners should be given basic skills on how to monitor, review, implement, document, report and discuss falls incidents aside from checking the patient, taking his vital signs and assisting the patients to get up on the floor (Pyrek, 2006, p. 276). This is more important on acquiring the whys and the hows of a specific incident or to always consider “Why did this happen?” Through this, they may possibly serve as emblem of a structured evaluation and subsequent implementation of falls strategies. The role of nurses is extended to collaborating with the families and promoting health, nutrition management, establishing supportive environments, collaborate with peers and provide opportunities for interdisciplinary collaborations on falls prevention. But the greater emphasis on the role of nurses and other medical associates are placed on improving processes. Put simply, staff nurses are effective sources of informations on identifying and acting on modifiable risk factors, improving care of vulnerable patients, providing synopsis of research evidence, detect and treat eyesight and hearing problems, suggesting ways to improve medication associated with falls and many others (Windsor, 2007).

Another study is conducted by Russell et al (2006) who contend that there is currently no standard approach to falls risk assessment and management for older fallers presenting to the emergency department who are discharged directly home. There is the necessity then to conduct such a study for the purpose of describing the prevalence of falls risk factors associated with older fallers presenting to the ED and identifying the factors associated with post-discharge decline function in this group. Hence, in achieving a holistic falls risk assessment could also mean delimiting such assessment with A&E to include the prevalence of falls risk factors at the time of discharge and onwards perhaps within a designated period of time. Other things that should be assessed are functional decline and objective measurements of balance, gait, depression and falls efficacy. There is a critical theme emerging from this which is the necessity of environmental audits. To wit, risk assessment and environmental audit tools are both needed in falls prevention as primary measures.  Environmental audit tools are comprehensive checklist of environmental risks factors. It could be applied to basically every place where the concentration of older people and risks are apparent.     

To further minimize the risks, it is also important to consider the risk assessment tools to be used. However, there are no screening tools that had been used or validated in a Hong Kong-wide practice to assess risk of falling among the elderly either in community or in residential care facilities. The available risk assessment tools that have been used in a number of trials and clinical settings are as follows: stratify risk assessment tool, FRAT, fall-risk screening test, Tinetti balance and gait scale, Physiological Profile Assessment (PPA), “Get Up and Go Test”, Mobility Interaction Fall Chart and classification tree of prediction (Todd and Skelton, 2004, p. 10). More than devoting the effort to design a Hong Kong-wide accepted risks assessment tool, I suppose attention must be given to addressing the independent risks factors independently. Should the fall evaluation suggest that assessment is inherent to the risks factors, then, I argue that there are no reasons to use a country-wide accepted assessment tool. Rather, medical practitioners should focus on a more ‘customised’ risk assessment devices, more especially in terms of appropriateness/specificity, applicability and sensitivity.

Implications for future practice

Besides educating the patients/residents in general regarding the nature and consequences of the falls, falls prevention education must also take into account identifying the factors that influences client compliance and non-compliance in falls prevention programmes. Fallers are always tended to defy the seriousness of a fall and/or dispose blame to others. These are implications of a later resistance to participate in falls prevention programmes (Lord, Sherrington and Menz, 2007, p. 209). Refusals are also considered opting to a level of acceptable level of risk factors. Though this can be tolerated at a certain degree, it is very dangerous to rely on circumstances. For people who have fallen, there is an evident overall lack of concern. Some perceived a fall to be natural part of aging process and others view different incidences as an opportunity to learn. These are all wrong. These may all lead to serious consequences in the long run. Taking this into consideration, preventing further falls and minimizing risks for these individuals are a challenge especially for interventionists.  There is a need to determine the patient’s interpretation of risks and interpretation of the incident as this critically affect the readiness to comply and participate with prevention programs. As a way to prevent falls, there is a need to communicate with first-time fallers the concept of prevention that should stem from individual willingness.

In particular, this falls risk assessment could be carried-out through cultivating to all staff on how they can act and serve as instruments to minimize risks among inpatient older people. The staff nurses have got to initiate best practices. Also, they could address the limitations of different strategies and probably address the aftermath solutions to falls. In this manner, they could do something to address the situation and give attention to several recommendations about falls prevention. Ward staff and risk management committee must be given the opportunity to do first level assessments, implement ‘customised’ risk screen and intervention tool in addition. This process could hone and enhance the research and development regarding falls prevention in older people. Prior to pursuing this initiative towards a more effective falls prevention program, there are issues to address. One is the availability of environmental audit tools. As already mentioned, there are ongoing debates on the subject of risk assessment tools. Literatures reveal that practitioners are more focused on this issue making them to overlook the necessity for environmental audit tools. Results could be documented and may serve as points of follow-ups for staff nurses and carers. The attempt to document and report points to the second issue. There are no specific and accepted documentation and reporting processes. Documentations and reporting are very crucial as it can address the root causes and later avoidance of recurrence of falls. HEN claimed that “there is a complex causal interaction between risks factors and falls occurrence” (Todd and Skelton, 2004). Indeed, but there is also a complex causality between risks factors, falls occurrence and, I maintain, falls reoccurrence. 

Conclusions

Falls could affect us directly or indirectly. Therefore, medical practitioners must do their part to prevent falls among elderly admitted within the hospitals and in A&E department mainly through assessing risks that jeopardize older people’s capability to function. Notably, falls prevention is not a single effort, it is a proactive, responsive and closed-loop initiative at least within the hospital setting, involving ward staff and risk management committee. Providing them a quality of life can be achieved through systematic enhancements outlined above. Minimizing the risks for the inpatient older people purports a close collaboration between these areas.

 

References

Chartered Society of Physiotherapy, The, 2001, Effectiveness of fall prevention and rehabilitation strategies in older people: implication for physiotherapy, Bedford Row, London

Davison, J, Bond, J, Dawson, P, Steen, I N and Kenny, R A 2005, ‘Patients with recurrent falls attending Accident & Emergency benefit from multifactorial intervention – a randomized controlled trial,’ Age and Ageing, vol. 34, no. 2, pp. 162-168.

Gillespie L D et al, 2003, Interventions to reduce the incidence of falling in the elderly. Musculoskeletal injuries module of the Cochrane Database of Systematic Reviews, no. 3.

Gray-Miceli, D 2007, ‘Fall Risk Assessment for Older Adults: The Hendrich II Fall Risk Model,’ Geriatric Nursing, vol. 8.

Lord, S R, Sherrington, C & Menz, H B 2007, Falls in Older People: Risk Factors and Strategies for Prevention, 2nd edn, Cambridge University Press.

Miller, C A 2006, Nursing for Wellness in Older Adults: Theory and Practices, Lippincott Williams & Wilkins.

Pyrek, K 2006, Forensic Nursing, CRC Press.

Russell, M A, Hill, K D, Blackberry, I, Day, L L and Dharmage, S C 2006, ‘Falls Risk and Functional Decline in Older Fallers Discharged Directly From Emergency Departments,’ The Journals of Gerontology Series A: Biological Sciences and Medical Sciences, vol. 61, pp. 109-1095. 

Standing, M 2008, ‘Clinical judgment and decision-making in nursing – nine modes of practice in a revised cognitive continuum,’ Journal of Advanced Nursing, vol. 62, no. 1, pp. 124-134.

Terrell, K, Weaver, B and Ross, M 2009, ‘ED Patient Falls and Resulting Injuries,’ Journal of Emergency Nursing, vol. 35, no. 2, pp. 89-92.

Todd, C & Skelton, D 2004, What are the main risk factors for falls among older people and what are the most effective interventions to prevent these falls? Copenhagen, WHO Regional Office for Europe (Health Evidence Network (HEN) report).

Tweedy, J T 2005, Healthcare hazard control and safety management, 2nd edn, CRC Press.  

Windsor, J 2007, Bite Size Best Practice: Falls Awareness, Portsmouth Hospitals (PHT), NHS Library Service: NHS Trust, no. 10.

 

Appendix

A number of methods and strategies regarding falls data collection will be employed. This will include a search and review of existing literature, patient observation and in-depth analysis of the literatures. A comprehensive review of the contributing literatures was done. Articles from medical institutions publication were scrutinized as well. This was undertaken to ensure the inclusion of several relevant published material and information. Various electronic databases were also visited including Chartered Society of Physiotherapy and World Health Organization (WHO). Different nursing books were also reviewed so that the researcher could acquire insights. The materials that have been used are comprised of published informations in the last ten years. The key terms used are: falls, falls prevention, inpatient older people, older people, risks factors, reducing risks, staff nurses and risk assessment.

Aside from using PICOT and CASP tools for assessing the journal research articles used, annotation was also used. In this way, I can relate to the readers the major questions posed in the study, method of investigation, major variables of interest and their operational definitions, study population, the findings, author’s or authors’ conclusion and the actual evaluation of their respective research. Three articles are chosen and these articles are original research. The key criterion is that the research should have the accident and emergency department as its setting. This would be appropriate especially that my practice in mainly within such department. Critical appraisal skills learned from the lectures are applied as much as possible. I regard that one of the limitations of my search strategy is own subjectivities.

PICOT stands for population/age group/gender, intervention/issue, context or comparison, outcomes and time while CASP is Critical Appraisal Skills Programme.

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