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Describe the Relevance of Clinical Governance to your project.

Causes and Consequences of Falls Among the Elderly

The aim of the project is to bring about 30% reduction in fall rates among the elderly population in a hospital ward within a six-month time frame by implementing exercise. 

Falls are the most common causes of morbidity, mortality and disability among the elderly. Falls in the elderly are a major concern and approximately 30% of falls occur each year (Milisen et al. 2013, pp. 495-507). Postural stability depends on the ability to coordinate the sensory and motor nerves, which in turn helps to perceive the environment and respond accordingly by controlling the movement of the body. Cognitive impairment has been identified as a risk factor associated with falls among the elderly, however, other diseases like dementia, depression and Parkinson’s disease have also been associated with falls among the elderly (Montero?Odasso et al. 2012, pp. 2127-2136). Subtle changes in cognition like executive function has also been associated with falls among the elderly. Recent research has revealed the importance of impairment of executive function is association with falls among the elderly people in hospitals. Assessments of executive function in the elderly needs to be carried out and should be a apart of the fall risk assessment carried out in the hospitals (Snyder 2013). There are various consequences associated with falls in the elderly. Injuries associated with falls in the elderly involve fractures of the hip, broken bones and broken hips, soft tissue injury, damages to the head, among others. These injuries in turn can give rise to serious consequences. Falls among the elderly results in loss of independence and many of the elderly population have to permanently reside in long-term care facilities. The risks associated with falls prevent them to carry out physical activities or any other daily activities, thereby restricting their movements. They feel isolated and this isolation can give rise to various mental disorders like anxiety, depression, among others. They become dependent on others to carry out their daily activities. The individuals who suffer falls have increased chances of  succumbing to falls again (Muir, Gopaul and Montero Odasso 2012, pp. 299-308; Winter, Watt and Peel 2013, pp. 215-227). Exercises have been shown to be beneficial as it helps to attain balance and build physical stability and strength, which is highly essential for such elderly population to lead a healthy life. According to Sherrington and Tiedemann (2015), various multi-component group based exrcises, gait and balance or functional training exercises have been shown to reduce falls among the elderly.  Therefore, the aim is to increase the balance and physical strength among the elders by carrying out different strength building exercises. 

Importance of Clinical Governance

Clinical Governance is a framework, which is used by the National Health Service Organizations, who are responsible for carrying out continuous improvements in quality of service and providing high quality care by providing an environment that encourages development of excellence in clinical care (Brennan and Flynn 2013, pp. 114-131). The seven pillars of clinical governance are clinical effectiveness and research, risk management, audit, education and training, involvement of patient and public, usage of information technology and staff management. The most relevant pillar is the pillar that deals with risk assessment and management. The nurses are required to assess the risk factors, critically analyse them and determine the probability of occurrence of any event that can cause harm to the patients. Moreover, they also need to implement approaches to reduce the risks and the impacts associated with such risks. The pillar of Clinical Governance that defines the identification of risk factors can be linked to this project as the nurses have to assess the risk factors associated with the falls of the elderly patients and provide necessary evidence based intervention strategies to reduce such fall rates in the hospital ward (Heyrani et al. 2012, pp. 84). Exercise programs will enable the elderly population to regain their balance and strength and in turn lead an active and independent life.

This issue is worth addressing, as exercises are known to reduce falls in the elderly. Exercises help to maintain balance and in turn provide strength and physical stability. Exercise can also improve heart functions and also help in maintaining good mental health, which in turn contributes to healthy and safe living (Blake and Hawley 2012, pp. 19-27).

In 2015 and 2016, falls were the most reported incidents in acute and community care hospitals and was the third most reported incidents in mental healthcare hospitals. About 250000 fall cases were reported in hospital settings. Falls among the hospital patients usually range between 2.3 to 7 falls per 1000 patients. The fall associated injuries include fractures, bleeding, subdural 

hematomas and death. Injuries associated with falls also increase the healthcare costs. A recent research revealed that during the research duration, the researchers observed 315817 falls, of which 26.1% gave rise to injuries. Patients above 80 years of age are more prone to succumb to falls, however patients of 65 years of age and below have also been found to succumb to falls. Falls are the leading causes of accidental death among the elderly population (Bouldin et al. 2013, pp. 13). The fall related injuries in Australia are reported to be over 60 in the year 2013. Studies have shown that exercises can decrease the rate of falls among the elderly and balance is considered to be an essential element of physical activity programmes (Tiedemann, Sherrington and Lord 2013, pp. 541-547). 

The Plan Do Study Act (PDSA) Cycle

The key stakeholders of the project could be the nurses or the care givers and the patients themselves. The nurses or the care givers can participate in the project by carrying out assessments of the risk factors of the patients that can give rise to the falls, analysis of the data and providing necessary intervention strategies in order to reduce the risk of falls among the elderly population. The nurses can educate the patients about the importance of exercises. The nurse can obtain feedback from the patients about the quality of care and develop or bring about improvements in their strategies in order to enhance patient satisfaction by giving rise to favourable outcomes. Other stakeholders may include the doctors and physiotherapists, help in designing the exercise program and determine the health issues during and after the exercise program.

Clinical Practice Improvement or CPI is a method for carrying out improvements and thereby providing high quality care. Clinical Practice Improvement ensures the quality, safety and efficiency of the provided care, enables accountability for the care either individually or as a group and brings about continuous improvements in the already established procedures. Clinical Practice Improvement provides a framework, which can be used by the healthcare professionals to carry out assessments regarding the causes associated with process failures, which in turn can cause harm to patients and bringing about solutions in order to carry out continuous improvements in care and patient outcomes (Rosenfeld, Shiffman and Robertson 2013, pp. S1-S55). The clinical practice improvement tool applied in the project will be the Plan Do Study Act. Plan Do Study Act or PDSA cycle involves undertaking small tests in order to bring about improvements. The PDSA cycle can be used to test a change by designing a plan, then carrying out the plan and subsequently observing and understanding the consequences of the plan. The PDSA cycle also 

involves determining the modifications that can be brought about in the plan to further improve it. The PDSA is an essential component of improvement practices in the healthcare settings. The stages of the PDSA cycle involves critical analysis of data that highlights poor performance, identifying the necessary causes associated with the poor performances, implementing small changes and monitoring the impact of the changes. Those changes that bring about positive outcomes are defined and established in order to be followed by all. The use of clinical practice improvement tools is a fundamental part of clinical governance. The benefits of PDSA involves establishment of new processes, involves the use of learning to bring about improvements, helps to reduce the costs of resources, provides scope for continuous development and improvement, helps to solve the problems associated with a large amount of data, increase process understanding, bring about improvements in outcomes and enhance teamwork. It can also provide customer or patient satisfaction and provide motivation to staff (Knudsen et al. 2017, pp. 45).  In this project the PDSA tool can be used by the nurses to critically analyse the risk factors associated with patient falls, identifying the causes, planning an exercise or physical therapy program, implement the exercise programs, monitoring the success associated with the exercise program and subsequently establishing the exercise programs in the daily routine of the elderly in the hospital ward (Taylor et al. 2013, pp.bmjqs-2013).  The small-scale strategies employed by the nurses can be the strength and balance building exercises that they can implement in order to help the elderly lead a health life. 

Exercise-Based Interventions to Reduce Fall Rates Among the Elderly

The elderly patients with cognitive impairment suffer from falls on a regular basis and this is as a result of impairment in their motor functions preventing them to properly analyse the environment and carry out necessary changes in the body movements. This in turn affects their balance, stability and gait (Morse, Merry and Bloswick 2016, pp. 341).

The first phase of the plan will involve the designing of the project and the necessary resources and the finances involved with it will be provided to the necessary finance department and the Director of the hospital, where the elderly succumb to such falls. Funds will be requested in order to carry out the project.

Exercise programs will be organized for the patients of the hospital ward and conducted under the supervision of physiotherapists. Exercises has been shown to reduce the risk factors associated with falls such as impaired balance and or mobility. Exercise programs that are aimed to bring about improvements in balance, strength and gait have been shown to reduce the occurrence of falls among the elderly (Cameron et al. 2012, pp. 1-121; Gillespie et al. 2012, pp. 1-299). It is 

necessary to educate the nurses about the importance of these approaches or intervention strategies. The exercise program will be carried out for six months under the supervision of the physiotherapists. The exercise program will be carried out 4 days a week for 1 hour and will include various strength and balance building exercise apart from free hand exercises as well. The improvements of the elderly people before and after the exercise programs will be monitored and such exercises once proven to be effective will be included in the daily activities of the elderly in order to reduce their fall rates and succumbing to injuries. The project can include an education package for the nurses and the care givers, where information will be provided about the importance of physical therapies to reduce the fall risks among the elderly. Moreover, the nurses can also be given appropriate training to carry out these exercises effectively. Such education packages can be developed by physiotherapists, fall management experts and senior doctors. The nurses can be trained by the physiotherapists in order to carry out physical therapy programs. The nurses should be encouraged to carry out frequent rounds of the patients and monitor their improvements. After the training necessary feedback can be obtained from the patients about the effectiveness of the training program. The nurses can monitor the patients by collecting their feedbacks, analysing the data obtained and provide the necessary patient specific care.

The various barriers to implementation of strategies to reduce the risks of falls among elderly people include normalization of falls. The elderly people perceive falls as normal according to their age and disregard such falls. There are various stigmas associated with falls among the elderly people. These include the fear of reporting the occurrences of falls as they believe that it will result in them being permanently transferred to long term care facilities. The older individuals believe that implementation of various interventions like exercises cannot prevent the occurrence of falls. They are fatalistic as they believe that nothing can improve their health and their ultimate fate is death. Another barrier is denial, where the elderly people refuse to understand that the cause of their falls is muscle weakness and loss of balance and strength (Biedenweg et al. 2014, pp. 1-11). The barriers associated with healthcare professionals include trivialization of falls, where they do not attach much importance to the occurrences of such falls and do not determine the causes of such falls. Many healthcare professionals lack the necessary skills and knowledge in management of falls among the elderly. Some healthcare professionals do not understand the value of exercising in preventing falls and are unaware of the effectiveness of exercises and physical therapy programs. Some of the healthcare professionals do not work in groups and do not have the relevant information needed to prevent the fatal injuries associated with falls. They do 

The various barriers to implementation of strategies to reduce the risks of falls among elderly people include normalization of falls. The elderly people perceive falls as normal according to their age and disregard such falls. There are various stigmas associated with falls among the elderly people. These include the fear of reporting the occurrences of falls as they believe that it will result in them being permanently transferred to long term care facilities. The older individuals believe that implementation of various interventions like exercises cannot prevent the occurrence of falls. They are fatalistic as they believe that nothing can improve their health and their ultimate fate is death. Another barrier is denial, where the elderly people refuse to understand that the cause of their falls is muscle weakness and loss of balance and strength (Biedenweg et al. 2014, pp. 1-11). The barriers associated with healthcare professionals include trivialization of falls, where they do not attach much importance to the occurrences of such falls and do not determine the causes of such falls. Many healthcare professionals lack the necessary skills and knowledge in management of falls among the elderly. Some healthcare professionals do not understand the value of exercising in preventing falls and are unaware of the effectiveness of exercises and physical therapy programs. Some of the healthcare professionals do not work in groups and do not have the relevant information needed to prevent the fatal injuries associated with falls. They do 

The various barriers to implementation of strategies to reduce the risks of falls among elderly people include normalization of falls. The elderly people perceive falls as normal according to their age and disregard such falls. There are various stigmas associated with falls among the elderly people. These include the fear of reporting the occurrences of falls as they believe that it will result in them being permanently transferred to long term care facilities. The older individuals believe that implementation of various interventions like exercises cannot prevent the occurrence of falls. They are fatalistic as they believe that nothing can improve their health and their ultimate fate is death. Another barrier is denial, where the elderly people refuse to understand that the cause of their falls is muscle weakness and loss of balance and strength (Biedenweg et al. 2014, pp. 1-11). The barriers associated with healthcare professionals include trivialization of falls, where they do not attach much importance to the occurrences of such falls and do not determine the causes of such falls. Many healthcare professionals lack the necessary skills and knowledge in management of falls among the elderly. Some healthcare professionals do not understand the value of exercising in preventing falls and are unaware of the effectiveness of exercises and physical therapy programs. Some of the healthcare professionals do not work in groups and do not have the relevant information needed to prevent the fatal injuries associated with falls. They do

not discuss and obtain advice from other healthcare professionals involved in the management of falls. Thus, they do not carry out interdisciplinary approaches in order to provide patient specific care. Thus, the patients are not referred to physiotherapists, occupational therapists and pharmacists in order to obtain favourable outcomes. Other barriers to implementation include inability to acquire the necessary resources and facilities in order to provide necessary care to elderly patients. Lack of equipments, facilities, staff and experts can also act as potential barriers to implementation (Loganathan et al. 2015, p. E008460).

Various evaluation strategies can be applied to determine the success of the project.  A before and after strategy can be carried out, where the knowledge of the nurses can be determined before the implementation of the education program and compare it with the knowledge after the end of the implementation program. Moreover, the rates of falls among the elderly can be measured before and after the implementation of the project. The rates of the falls before and after the project can be statistically represented in the forms of bar charts and other graphs in order to evaluate the success of the program. Moreover, feedbacks can be collected from the patients about the efficacy of the exercise programs and whether such strategies are providing them with favourable outcomes. The success of the implementation of the education package can be evaluated by obtaining feedback from the nurses about how these education and training programs helped them to provide effective care to the patients. Moreover, questionnaires can also be used to evaluate the knowledge of the nurses about effective exercise strategies with the aim to reduce the risk of falls among the elderly. The data obtained from the questionnaires can be used to evaluate the knowledge improvement of the nurses and percentage of the improvement can be obtained by comparing it with the evaluation done at the initial stages of the project (Singh and Okeke 2016, pp.u210921-w4741).

Reference List

Biedenweg, K., Meischke, H., Bohl, A., Hammerback, K., Williams, B., Poe, P. and Phelan, E.A., 2014. Understanding older adults’ motivators and barriers to participating in organized programs supporting exercise behaviors. The journal of primary prevention, 35(1), pp.1-11.

Blake, H. and Hawley, H., 2012. Effects of Tai Chi exercise on physical and psychological health of older people. Current aging science, 5(1), pp.19-27.

Bouldin, E.D., Andresen, E.M., Dunton, N.E., Simon, M., Waters, T.M., Liu, M., Daniels, M.J., Mion, L.C. and Shorr, R.I., 2013. Falls among adult patients hospitalized in the United States: prevalence and trends. Journal of patient safety, 9(1), p.13.

Brennan, N.M. and Flynn, M.A., 2013. Differentiating clinical governance, clinical management and clinical practice. Clinical Governance: An International Journal, 18(2), pp.114-131.

Cameron, I.D., Gillespie, L.D., Robertson, M.C., Murray, G.R., Hill, K.D., Cumming, R.G. and Kerse, N., 2012. Interventions for preventing falls in older people in care facilities and hospitals. The Cochrane Library, pp. 1-121.

Gillespie, L.D., Robertson, M.C., Gillespie, W.J., Sherrington, C., Gates, S., Clemson, L.M. and Lamb, S.E., 2012. Interventions for preventing falls in older people living in the community. The Cochrane Library, pp. 1-299.

Heyrani, A., Maleki, M., Marnani, A.B., Ravaghi, H., Sedaghat, M., Jabbari, M., Farsi, D., Khajavi, A. and Abdi, Z., 2012. Clinical governance implementation in a selected teaching emergency department: a systems approach. Implementation science, 7(1), p.84.

Knudsen, S.V., Laursen, H.B., Ehlers, L.H. and Mainz, J., 2017. ISQUA17-3217 There is need for improvement of quality improvement-a systematic review of the PDSA method in QI studies. International Journal for Quality in Health Care, 29(suppl_1), pp.45-45.

Loganathan, A., Ng, C.J., Tan, M.P. and Low, W.Y., 2015. Barriers faced by healthcare professionals when managing falls in older people in Kuala Lumpur, Malaysia: a qualitative study. BMJ open, 5(11), p.e008460.

Milisen, K., Coussement, J., Arnout, H., Vanlerberghe, V., De Paepe, L., Schoevaerdts, D., Lambert, M., Van Den Noortgate, N., Delbaere, K., Boonen, S. and Dejaeger, E., 2013. Feasibility of implementing a practice guideline for fall prevention on geriatric wards: A multicentre study. International journal of nursing studies, 50(4), pp.495-507.

Montero?Odasso, M., Verghese, J., Beauchet, O. and Hausdorff, J.M., 2012. Gait and cognition: a complementary approach to understanding brain function and the risk of falling. Journal of the American Geriatrics Society, 60(11), pp.2127-2136.

Morse, J., Merry, A. and Bloswick, D., 2016. Research Approaches to the Prevention and Protection of Patient Falls. Fall Prevention and Protection: Principles, Guidelines, and Practices, p.341.

Muir, S.W., Gopaul, K. and Montero Odasso, M.M., 2012. The role of cognitive impairment in fall risk among older adults: a systematic review and meta-analysis. Age and ageing, 41(3), pp.299-308.

Rosenfeld, R.M., Shiffman, R.N. and Robertson, P., 2013. Clinical practice guideline development manual: a quality-driven approach for translating evidence into action. Otolaryngology—Head and Neck Surgery, 148(1_suppl), pp.S1-S55.

Sherrington, C. and Tiedemann, A., 2015. Physiotherapy in the prevention of falls in older people. Journal of physiotherapy, 61(2), pp.54-60.

Singh, I. and Okeke, J., 2016. Reducing inpatient falls in a 100% single room elderly care environment: evaluation of the impact of a systematic nurse training programme on falls risk assessment (FRA). BMJ quality improvement reports, 5(1), pp.u210921-w4741.

Snyder, H.R., 2013. Major depressive disorder is associated with broad impairments on neuropsychological measures of executive function: A meta-analysis and review.

Taylor, M.J., McNicholas, C., Nicolay, C., Darzi, A., Bell, D. and Reed, J.E., 2013. Systematic review of the application of the plan–do–study–act method to improve quality in healthcare. BMJ Qual Saf, pp.bmjqs-2013.

Tiedemann, A., Sherrington, C. and Lord, S.R., 2013. The role of exercise for fall prevention in older age. Motriz: Revista de Educação Física, 19(3), pp.541-547.

Winter, H., Watt, K. and Peel, N.M., 2013. Falls prevention interventions for community-dwelling older persons with cognitive impairment: a systematic review. International psychogeriatrics, 25(2), pp.215-227.

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