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Journal Of The American Geriatrics Societ

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Individualised balance exercises would be achieved through the collaboration of the specific patient and physical therapist or nurse assistants. Hence, the pillar of consumer and community participation is relevant to the project. Based on consumer and community participation pillar, an intervention is developed on the principles of consent, autonomy and professional ethics.  The patient at the aged care home should offer consent before the therapist initiates therapy session. On the other hand, the healthcare professional should practice autonomy and observe professional ethics when treating the patient. Besides, needs assessment, information provision and privacy are fundamental aspects of the consumer and community participation pillar (Department of Health, 2012). These principles are all pertinent to the proposed project. Another clinical governance pillar that is pertinent to the project is service evaluation, quality improvement and innovation. The structure of the project requires constant evaluation and improvement based on the client’s outcomes and efficiency. The pillar of service evaluation and quality improvement suggests that treatment should be monitored progressively and updated to meet the envisioned or desired results (Department of Health, 2012). In this project, the individualised balance exercises will be continuously monitored, and deficiencies in relation to the predetermined standards of care will be remedied. This analysis indicates that clinical governance is relevant and indispensable to the proposed project.


Evidence that the issue / problem is worth solving: (774 words)

Falls in nursing homes is a significant problem that results in adverse health outcomes and is a common occurrence in Australian aged care facilities. Empirical evidence suggests that there is a high number of falls in nursing homes. Ibrahim and colleagues, in their study conducted between 2000 and 2013, found that most deaths in accredited Australian nursing homes occur due to falls. Specifically, they revealed that out of 21672 deaths 81.5 percent (2679) are associated with falls. They concluded that falls cause premature deaths in aged care facilities, which are preventable (Ibrahim et al., 2017).  

One study conducted in New South Wales (NSW), shows that there is a high number of falls in residential aged care that require medical treatment. The study shows that between 2006 and 2007 5756 falls were requiring medical attention in NSW. The number of falls that needed emergency department attendance in nursing homes was about 6988. Lastly, the number of falls in residential aged care that required non-hospital treatments was 29790 (Watson et al., 2010).

Another justification for implementing a fall prevention strategy in nursing homes is the incidence report of Queensland health facilities. Between 2007 and 2008, 11928 fall-associated clinical incidents in Queensland. 22 percent of these incidences occurred in nursing homes. Some of these incidents led to mortality or severe and permanent patient harm. Other incidents led to temporary loss of function, while a few did not cause any harm (Black & Ferrar, 2011).

Chen and colleagues did a study to determine the prevalence of falls in nursing homes in Australia.  In this study, there were 1342 older males and females with a mean age of 86 years. Over a period of 1.97 years, approximately 6646 led to 308 fractures. Some fractures resulted in long hospitalisation and disability. This study shows that falls in nursing homes should be prevented to enhance the quality of life for the residents (Chen et al., 2008).

Fall-associated ambulance attendances for Queensland also reveal the prevailing problem of falls in aged care facilities.  From 2007 to 2008, there was an average of 1895 fall-linked attendances. About 24 percent of all the falls occurred in aged care facilities around Queensland. The report indicates that most of these falls needed treatment at the scene (Black & Quinn, 2010).

Nicholas and colleagues did a study in nursing homes in Sydney to investigate the prevalence of falls linked to Drug Burden Index. The study found that there are many falls in the aged care homes associated with the medication. In one year, there were 998 falls in 330 clients. The analysis insinuates that the average falls per person in a year is 1.74 (Wilson et al., 2011).  

In a study conducted in Australia between 2009 and 2010, it was found that one in five injurious falls involving an individual aged 65 years and older occurred in nursing homes and led to hospitalisation. Within the same period, the prevalence of fall injury cases in nursing homes was six times higher than in homes (Bradley, 2013).

Finally, this project is supported by the AIHW report of 2005-2006. Based on this report, the largest number of fall injury incidences happened in nursing homes, which was 21.8 percent. The falls in women were 23.6 percent, while in men the falls were 17.5 percent.  The report notes that in the number of falls in aged care facilities was five times higher compared to the home environment (Bradley & Pointer, 2008).

Recent literature suggests that individualised balance exercise is effective in reducing falls in nursing homes. One review article asserts that balance training using mechanical apparatus reduces falls in intermediate level nursing homes (Cameron et al., 2012). Besides, research found that high-intensity exercise reduces falls in older people living in aged care facilities if they enhance their balance.  This study involved 191 older people living in nursing homes (Rosendahl et al., 2008). A meta-regression study found that interventions that entail balance training, excluding walking training have a significant impact in reducing falls in older adults. The meta-analysis recommends the balance exercise to be performed for about two hours per week (Sherrington et al., 2011). Raimunda and colleagues did a meta-analysis of 12 studies involving 1292 candidates to determine the effectiveness of exercise in fall and fracture prevention. Their analysis notes that balance exercises have a preventive impact on falls (Silva et al., 2013). 

The problem: A fall is an act of collapsing without control. In nursing homes, falls can be sudden and can happen at any place within the aged care facility. Exercises are designed, structure and repetitive movements to enhance or sustain certain components of physical fitness (Tiedemann et al., 2013).

Key Stakeholders: (135words)

Nurse assistants – Nurse assistants, will act as the primary caregivers for the patients in nursing homes. They will identify residents within nursing homes who should be included in the program. 

Registered nurses (RNs) - RNs will be required to monitor residents who are undertaking balance exercises. They will ensure the patients maintain appropriate hygiene and receive proper nutrition.

Physiotherapists – These specialists will examine and treat residents who can benefit from balance exercises. Their role will be restoring and maintaining physical function within musculoskeletal systems. 

Orthopaedic surgeon – This medical professional will be involved in examining musculoskeletal system disease among the patients. They will determine patients who are the risk of experiencing osteoporosis.

Patient representatives - The patient advocates will be responsible for maintaining communication with the patients and healthcare providers in the course of the program.


CPI Tool: (329 words)

The CPI tool that will be used for this project is PDSA (Plan, Do, Study, Act). PDSA is an iterative tool appropriate for performing change or improving a process.

Plan: The initial step is to plan the change that will be trailed. The process that needs improving is identified and a mission statement drafted. Additionally, the evidence is collected at this stage as well as the formation of an appropriate team (NSW Health Department, 2002). The planning stage relates to the four parts of this project which are project title, project aim, evidence that the issue is worth solving and key stakeholder analysis.

Do: The trail of the proposed change is performed. In this stage, the plan is executed or set in motion. An understanding of the event is required for accurate investigation.  Observations on the performance of the interventions are made in the Do stage. This stage relates to the summary and proposed intervention part of the project.

Study: This stage entails the evaluation of the trail impact. The observations and data collected in the DO stage are used to determine whether the plan led to an improvement (NSW Health Department, 2002). The main aim of the Study stage is to measure whether the project aim is achieved. This stage relates to the evaluation part of the project.

Act: The last stage involves the implementation of the changes that have proven to be effective. The conclusions of the project are made at this stage. If the plan led to success, the improvements are standardised and constantly used to solve the problem. This stage relates to the “barriers to implement and sustain change” part of the project.

The PDSA could be used to address the aim and implement the intervention in the following ways. It could be used to identify and diagnose the fall problem and measure the extent of the problem. Then an appropriate intervention could be identified, implemented and re-measured to ascertain whether it has been effective.

Summary of proposed interventions: (233 words)

 Balance control is the foundation of an individual’s capacity to move, walk and function independently. The individualised balance exercises would include dual as well as multi-task exercises. These exercises have been proposed based on the understanding and principles that, balance control depends on the coordination of physiological systems, interaction with the task performed and environmental factors (Halvarsson et al., 2015). 


Project outline

Nurse assistants conduct risk assessment will identify and refer the older adults at the aged care facilities who are the risk of falls. The nurse assistants will be required to use Physical Mobility Scale to determine the individuals who are the risk of falling.

The residents of nursing homes who have been referred by nurse assistants will be examined by the RNs and orthopaedic surgeon to determine their eligibility for the balance exercises. Eligible clients will be enrolled.

The physiotherapist will develop an individualised treatment for patients based on their health condition. The balance exercises will be categorised into basic, moderate and advanced levels. Basic level will include dynamic balance as well as sensory orientations. Advanced level will include stability limits, dynamic balance and sensory orientation. The advanced level will include multi-task exercises.

Individualised exercises will be performed for at least 3 hours per week for 12 months. The effectiveness of the project will be evaluated in the first six months and the second at the end of the 12 months.


Barriers to implementation and sustaining change: (187 words)

Staff education will be one of the barriers to the implementation of the project. The aged care facility staff requires training on how to utilise risk assessment tools and should be in a position to delineate the pragmatic for conducting a fall assessment on admission. They should also be trained about predisposing and factors that might trigger falls, which can be prevented through balance exercises.  This barrier can be addressed through ongoing training.

Obtaining baseline data before the execution of the project is another challenge.  Before the project is executed, there is a need for the current baseline for cases of falls in aged care facilities. The data would be used to determine whether previous interventions have been successful and whether the individualised balance exercise would be successful. This barrier would be addressed by conducting an initial study of the falls in nursing homes to gather the required baseline data.

The cost of implementation is also a barrier. The costs would be incurred in risk management, documentation, acquisition of supplies and equipment. This barrier would be solved by involving state and territory governments to fund the project.

Evaluation of the project: (122 words)

The evaluation of the project would be based on outcomes to determine the advantages to the patients.  Data on the number of falls in aged care facilities would be the foundation of the evaluation. A poised mixed model will be used to analyse the number of falls. This model has been used by Hewitt and colleagues to evaluate the number of falls in nursing homes (Hewitt et al., 2014). During the evaluation, data would be recorded based on the time of day, the circumstance of fall, location and activity. The data would help to determine the type of fall like accidental, predicted physiological and unpredicted physiological fall. A decline in the number of accidental falls will suggest that the project is successful.



Black, A. & Ferrar, K., 2011. Fall-related clinical incidents reported in Queensland Health facilities, 2007- 08. Brisbane: Queensland Health. Retrived from

Black, A. & Quinn, J., 2010. Falls-related ambulance attendances for Queenslanders aged 65 years and over, 2007-08. Brisbane: Queensland Health. Retrieved from

Bradley, C., 2013. Hospitalisations due to falls by older people, Australia 2009–10.. Injury research and statistics series no. 70. Cat. no. INJCAT 146. Canberra: AIHW. Retrieved from

Bradley, C. & Pointer, S., 2008. Hospitalisation due to falls by older people, Australia 2005–06. Injury research and statistics series number 50. Cat. no. INJCAT 122. AIHW. Retrieved from

Cameron, I. et al., 2012. Interventions for preventing falls in older people in care facilities and hospitals. The Cochrane Library, (12), p. CD005465.

Chen, J. et al., 2008. Risk factors for fracture following a fall among older people in residential care facilities in Australia. Journal of the American Geriatrics Society, 56(11), pp.2020-26. Retrieved from

Department of Health, 2012. Appendix C: comparison of with ATAPS clinical governance framework. [Online] ( [Accessed 2 October 2017].

Halvarsson, A., Dohm, I.-M. & Stahle, A., 2015. Taking balance training for older adults one step further: the rationale for and a description of a proven balance training programme. Clinical Rehabilitation, 29(5), pp.417-25.

Hewitt, J. et al., 2014. Does progressive resistance and balance exercise reduce falls in residential aged care? Randomized controlled trial protocol for the SUNBEAM program. Clin Interv Aging, 9(1), pp.369-76.

Ibrahim, J.E. et al., 2017. Premature deaths of nursing home residents: an epidemiological analysis. Medical Journal of Australia, 206(10), pp.442-47. Retrieved from

NSW Health Department, 2002. Easy guide to clinical practice improvement: A guide for healthcare professionals. [Online] Available at: [Accessed 2 October 2017].

Rosendahl, E. et al., 2008. A randomized controlled trial of fall prevention by a high-intensity functional exercise program for older people living in residential care facilities. Aging Clinical Exp Res, 20(1), pp.67-75.

Sherrington, C. et al., 2011. Exercise to prevent falls in order adults: an update meta-analysis and best practice recommendations. NSW Public Health Bulletin, 22(3-4), pp.78-83.

Silva, R.B., Eslick, G.D. & Duque, G., 2013. Exercise for falls and fracture prevention in long term care facilities: A systemic review and meta-analysis. JAMDA, 14, pp.685-89.

Tiedemann, A., Sherrington, C. & Lord, S., 2013. The role of exercise for fall prevention in older age. Motriz: Revista de Educação Física, 19(3), pp.541-47.

Watson, W., Clapperton, A. & R, M., 2010. The incidence and cost of falls injury among older people in New South Wales 2006/07. Sydney: NSW Department of Health. Retrieved from

Wilson, N. et al., 2011. Associations Between Drug Burden Index and Falls in Older People in Residential Aged Care. Journal of the American Geriatrics Society, 59(5), pp.875-80. Retrieved from


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