Discuss about the Evidence Based Nursing Research for Hospitalisation.
In Australia around 96,300 elders belonging to the age group of 65 and above were hospitalised due to fall during 2011-12. (AIHW 2016). The fall percentage in women is higher than the men. With increasing fall incidences every year in the elderly, the concern to develop methods to control has risen. Around 40% of injury-related death in the elderly population is due to fall. The common injuries due to fall include bruises, cuts and sprains. Hospitalisation is needed in case of fractures. Fracture in hip is one of the major reasons of mortality and morbidity due to slow recovery from the surgery. This is also affecting the quality of life of the elderly people as they have a fear of falling. (Aus & New Z: Falls prevention society 2016). Many studies to find effective techniques and method in order to prevent the fall related injuries in the elderly population have been conducted. The given article presents the review of one such randomised and controlled trial conducted by Elley et al. (2008) on the effectiveness of a falls- and-fracture nurse coordinator to reduce falls in older adults.
The study emphasizes on the multifactorial and single factor intervention to be effective in reducing fall in the trial group of participants. The cost incurred due to the fall prevention methods on the community has encouraged people to invest in the effective to reduce fall.
The researcher has selected a multifactorial intervention using a falls and fracture nurse coordinator who is working with the family physician of the participant. They aim to reduce the fractures by improving the bone strength by the family physician. The trial format was randomised and controlled method conducted in Hutt Valley, Wellington, New Zealand. The duration of the trial was around two years, from March 2005 to February 2007. A randomised controlled trial consists of participants who are assigned to treatment condition at random using controlled procedures. This method helps in comparing the interventions with the control and examining the affecting factors which can help reducing the risk. Randomised control trail is mainly used for the observational and quasi-experimental designs as there is possibility of potential bias and confounding. This could be due to the lack of comparability, observer bias and secular trends. In this case randomised control trial gives the gold standard for the determination of the study. (Koch, A.U. 1999). The participants selected included men and women from age group of 75 years and above having a fall history in 12 months periods. A baseline assessment was done by the nurses recruited for the care intervention. A computer based schedule generated for the intervention or control group was given to the participants from the researcher at random. This approach is effective as the chances of bias are low. All the participants received the standard methods of intervention which will help in the analysis. The comparison between the groups can be easy using the control trial method. The researcher excluded the participants having problems in understanding the guidelines, those with serious medical conditions and those who were physically disable. This would help in getting the expected outcome.
Although the overall technique was ineffective considering the fact that in old age it is difficult to follow guidelines and act accordingly. Besides since the measures were based on the references to other professionals who follow their clinical practises. This can create the chances of internal contamination. The effective methods could be to incorporate more exercise interventions along with the dietary supplement and medicinal factors. Exercises have been proved to be one of the most effective methods to control fall in elderly population. The exercises which focus on balancing and strengthening of muscles have shown positive results in this regard. (Li et al 2005).
The method was approved by The Wellington Ethics Committee and was registered with the Australia New Zealand Clinical Trial Register. The study met the ethical requirement as the selection was done considering the age factor and related issues. The willingness of the participants was considered while selection. The ethical requirements of the study were to determine the effect of fall prevention technique in the elderly, the problems which can be faced by the participants and the implication of measures that require physical restraints. The method was well explained so the ethical determination of the study was well established.
Fall prevention is an issue which is now catching the eye of researchers to develop effective control measures. There is less research or literature available on the issue. (Glasziou 2008). Measures are published in many countries like USA, UK and Canada to reduce the fall in the old age people. (Guidelines 2001; Feder 2000; Scott 2001). Strategy based research study involves the factors which can be effective to reduce the fall rate and community based study involves the implication of the strategies and measures to a large mass group. It is different from the randomised control trial studies which focus on a particular group of individuals within a community. They are set in different environmental backgrounds. (McClure et al 2008).
The measurement technique used by the researchers included recording of the number of falls on daily and monthly basis and there was a follow up call by the researcher who is blind to the group allocation. They recorded the injuries and hospitals interventions. A single follow up visit were made in 1 year assessment to the participants to check the muscle strength and body balance. The measurement of daily activity and the fear to fall was also assessed. The interventions were measured by a trained nurse who visited the participants and analysed the various associated factors for the intervention. The number of participants at various stages was presented by researcher in a flow chart. They conducted a session for the family physicians top explain the guidelines related to the fall prevention.
Considering the JBI level of evidence the study failed to acknowledge the main components. The approach of the study is weak to analyse the effects. The multifactorial intervention techniques have proved to be ineffective in the fall reduction in older people. The community based studies have been an effective method to analyse the measures to reduce fall. Nine trials conducted to check the efficiency of multifactorial studies in order to reduce fall in older people showed negative results. The lack of empirical data in the multifactorial studies done on older people in their home environment was also responsible for the failure of such trials. (Balzer 2012). Only 1 visit for assessment in a year trial is inefficient to determine the effectiveness and outcomes of the interventions. Out of 3434 people only 312 fulfilled the requirement and were willing to participate. The randomisation was almost equal in the study. The primary outcome related to fall reduction showed only 0.95% incident rate ratio in the intervention group on comparison with the control group. The secondary outcome was also showing a higher difference. The proved that guidelines for the exercises to increase the strength and body balancing old age people along with the routine activity were not effective.
The factors associated with the failure of study could be mainly the fault in the study design. The insufficient visits for the analysis, the lack of support from the physicians proved to be a factor which decreased the efficacy of the study. The study method was also ineffective to analyse the result. There were several trials conducted by Gillespie et al (2012) to determine the effective techniques to reduce fall in elderly. The effective measures to reduce fall include many factors including exercises, vitamin D supplement, education related to the issue, treatment methods, safety measures and proper care etc. the efforts made in the direction of improving of the older people and to reduce the fall needs to observe on a broader prospect and worked accordingly. (Marks, R 2008).
The data collection used in the study was through the post card calendars which the candidates filled in each day and on the monthly basis to record the fall rate. The researcher had the records on the telephone after 4 weeks in the primary outcome but during the secondary outcome they limited it to one visit after 12 months. They should have taken the records in less time interval for more effective outcome.
The JBI Level of Evidence
The researcher considered the probable questions which could have led to the ineffectiveness of the study. The researcher claims that the study was robust considering the previous studies related to the issue. The problems that affected the study as per the researcher was the involvement of the family physician and their referred interventions. The researcher has established that the physicians were made to attend the session on the measures of the study and the required outcomes.
The researcher used STATA 9.1 with negative binomial regression model to compare the falls in the intervention and the control group. The secondary outcome was transformed into log for the analysis. To compare the changes in the secondary outcomes, the method used was linear and ordinal logistic regression models for baseline values. The method was used to compare the data between the group. It is effective for the randomised control study
Fall is considered as one of the major factor leading to the morbidity and causing disability in the older people. Nearly one third older people of age above 65 years are victim of fall and in around half cases this case is frequent and recurring. (Tinetti and Kumar 2010). To reduce the fall more number of studies need to be conducted. A proper lay out is required which covers all the factors including exercises and medicinal interventions. As a physician I would not select this method mentioned by Elley et al. (2008) as it failed to prove the efficiency of multifactorial intervention in community based trial method. My approach would be to use plans and method which are more efficient in improving the health of the old people. Exercise related to strengthening the muscles and balancing have proved to be effective to reduce fall. I would prefer using methods which can reduce the fear of falling in the patients. A method suggested reducing fall in elder people by Aama T. A (2011) represents all the essential elements which are must to be considered. In future such approach will prove effective in dealing with this issue.
The literature review presents the study trial to reduce fall in elderly. Although the approach followed a robust trial method yet due to lack of proper analysis technique and data collection methods, the study failed to be effective in this regard. Lack of research in this matter is evident in many studies. It is time to look for an effective method to reduce the fall in elderly people. Cost effective methods and government approved guidelines are needed. All the possible threats to the trial should be considered including the bias, confounding and regression should be analysed. Trial on mass basis with the use of strategic rigour to combat the several hindrances and errors related to the study should be applied and used.
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