Aim- The aim of the project is to build the intervention of interdisciplinary partnership in nursing practice for risk assessment of falls based on two most suitable risk assessment tools among the elderly patient.
Relevance of Clinical Governance to your project
Falls prevention in the older adults is a fundamental safety and quality health care area. Clinical governance of the falls prevention in elderly is a combined component of governance of health service organisations. It assures that each of the relevant professionals varying from clinicians to managers and members of governing bodies, are responsible for the elderly people for ensuring safe, efficient, collaborated, high quality and continuously improving care delivery. Clinical governance should be established and maintained by all the health care professionals to promote safety and quality. Nurses should have the ability to identify safety and quality measures, and find out areas which has scope of improvement in delivering safety and quality to the elderly population at the risk of falls. They should include the service users or their families while reviewing safety and quality performance and systems (ACSQHC, 2017). A review which studied 40 trials to evaluate the efficiency of the relative effectiveness of interventions to prevent falls in elderly population found that the most effective intervention is a multifactorial falls risk assessment and management programme. These interventions were able to promote patient safety by lowering the risk of falls and declining monthly rate of falling as well (Chang, et al., 2004). This finding is suggested by other secondary evidences as well (Shi & Chunhu, 2014), (Gillespie, et al., 2012).
Evidence that the issue / problem is worth solving:
The intervention will have a preventive approach rather than a restorative direction. It is more rational to prevent the occurrence of falls in elderly population rather than treating the fallen patient to gain favourable outcomes as due to the increased age, the physiological structure and functioning may take the fall more severely as well as do not heal easily (Luk, Chan, & Chan, 2015). Falls among the elderlies have a damaging impact on the health and quality of life of the person and increases the financial and caring burden on family and the health care system, therefore, screening and assessment for fall risk are significant interventions for nursing practice (Akyol, 2007). In addition, on screening by the nurse, if risk factors of falling are present in an elder person, it could be identified and then the nurse can collaborate with other practitioners of other disciplines in order to deliver the required ambulatory, hospital or community interventions to remove those risks (Cuevas-Trisan, 2017). For example, if a nurse observes that an individual has difficulty in rising from chair, the she can conclude from her knowledge that it indicates proximal muscle weakness and she can refer the individual to a physiotherapist for lower extremity strengthening. The physiotherapist will provide the required management so that the individual is able to overcome the difficulty and the risk of fall is removed leading prevention of fall (Lee, Lee, & Khang, 2013). A review found that the existing fall risk assessment tools used for the elderly do not demonstrate adequately high predictive validity for differentiating high and low fall risks. So, in the proposed intervention it is suggested that instead of a single measure, two assessment tools should be used together in order to attain and improved evaluation of the characteristics of falls among the elderly (Park, 2018).
The key stakeholders involved in the intervention would be the nurses and professionals from other disciplines such as physiotherapist, Occupational therapist, clinicians, social workers, specialist doctors and organisational healthcare leaders. Apart from the elderly person along with their family members are also identified as key stakeholders. The leaders must ensure that the nurses are skilled and qualified enough to identify two most relevant risk assessment tools to screen the elderly population based on their health condition. They may be required to bring experts and schedule training programs for nurses. Nurses and other professionals will be involved to have an appropriate training of multidisciplinary working so that no challenges are faced while referrals or other collaborative functioning. The service users and their families must be able to understand the need and their role in implementing the interventions to promote safety of the elderly person.
Plan-Do-Study-Act (PDSA) /model
PDSA (Plan-DO-Study-Act) is a four-step model used to obtain relevant knowledge for continual improvement of a process. To improve the nursing practice particularly for prevention of falls in elderly, PDSA cycle can be used (Hughes, 2008).
1.Plan- In the planning stage, the first step is to set a set a goal for the improvement process which this project is to build the intervention of interdisciplinary partnership in nursing practice for risk assessment of falls based on two most suitable risk assessment tools among the elderly patient. Goal setting will enable its easier communication to the relevant stakeholders. After setting the ultimate goal, incremental objectives will be defined to measure the short term progress. It will be done by identifying the gaps in current and desired state of nursing practice. Therefore, one of the objectives will be to educate the nurses through weekly sessions for 3 months regarding screening and risk assessment tools for prevention of falls among elderly by an experienced specialist. Next, the nurses along with other professionals can be given interdisciplinary training twice a month through meetings, discussions or other simulating activities to speed up referrals and encourage good communication. Lastly, in the planning stage documenting of the set goal, identified objectives, interventions and strategies is done in the form of an action plan.
2.Do- In the doing stage, after the identification of goal and strategy, performance metrics are specified in order to evaluate whether a change is actually resulting in the desired improvement. So, in order to identify that the specified goal is resulting in improved nursing practice particularly with elderly care, it is essential to specify certain performance metrics. One of the objective is to speed up specialist referrals by the nurses. It can be assessed by measuring the time it takes to get a response from the specialist or his organisation. Another objective is accurate identification of risk assessment tools by the nurses. It can be assessed by measuring the monthly rate of fall among the elderly patient or seeking feedback from the service users or their families regarding their experience and the occurrence of fall post risk assessment.
3.Study- In the studying stage the actions are refined. The refinement of the actions can assist in modifying the interventions so that desired improvement is achieved in the nursing practice. The identified strategies will be checked regularly in order to find out whether they are meeting the needs of the service users, that is lowering the risk of falls. They must also meet the needs of the nursing staff that is they are able to gain continual improvement.
4.The Acting stage is the final stage which will include adoption of the interventions and assessing it against the goals of the improvement project and for tracking improvement progress. So, in this stage it will be checked whether the intervention was effective in lowering the time required to see an expert through referral. It will also check whether the elderly population and their family members reported an improved experiences in the care delivered by nurses and whether the occurrence of falls actually declined or not.
Summary of proposed interventions:
Elderly population faces a serious issue of falls in the care institutions as well as homes. A frequent error in the nursing management of the falls is that the injury from the fall is treated, without identifying its cause, so an active approach is significant to screen for the chances of fall in the elderly population. This improvement project for nursing practice includes a set of interventions that needs to be adopted in order to implement the preventive approach to lower the rate of falls among elderly population. The proposed interventions are:
1.Nursing practice must involve a comprehensive fall assessment to evaluate the likelihood of risk among elderly population. It is identified in literature that identification of suitable risk assessment tool is essential to correctly assess the chances of risk. Single tool may fail to offer all the relevant characteristics of fall so, the nurses must make of use two most appropriate risk assessment tool to evaluate the risk of falls among elderly. The tools must be based on history and targeted examination of the patient.
2.Second intervention is implementation of multidisciplinary working in order to deliver best possible assessment and interventions to the service users in quick way. Nurses must collaborate with professionals from other relevant disciplines to provide an improved service experience to the service users and their families by inducing fast referrals through effective flow of communication between different departments. Effective risk assessment will only help in prevention of fall if adequate interventions are provided in order to minimise the risk.
Nurses will be able to improve their practice by adopting the above mentioned interventions.
Barriers to implementation and sustaining change:
The changes that need to be implemented to improve the clinical practice of nurse to lower the rate of falls among elderly may face various barriers during implementation or sustaining stage.
To bridge the knowledge gap among the nurses about the risk assessment of fall, it is suggested to conduct workshops or educative sessions by the expert. However, nurses face a workload in their practice, it can be difficult for them to find extra time for the sessions. Time constraint is a barrier in implementing the change. To remove the barrier the nurse leader must develop a duty schedule for the nurses which will allow them to attend the weekly sessions without having any additional load and increased working hours.
At the sustaining stage, a range of barriers can be faced by the nurses during multidisciplinary working. There might be lack of clarity of role and responsibilities of different professionals in the collaboration which might be a source of confusion for the service user as well the staff. It is essential that the professionals work towards the common shared goal by understanding their duties and performing them to the best of their abilities. In case of confusion they must be willing to cooperate with other to settle the dispute. In extreme cases, a formal conflict resolution must be used.
Another barrier is ineffective sharing of information between nurses and other practitioners. With the lack of required information, service provision may get delayed, hindered or completely stopped. This will eventually result in inefficient nursing practice. This barrier can be removed by appropriate record-keeping by nurses. When the information about the elderly patient is documented clearly and timely, it will assist the nurses as well as other professionals in continuity of care. Further, it saves the patient from the repeating the same information again and again leading to an improved service experience.
Evaluation of the project:
The project can be evaluated by applying various techniques:
The elderly population or their family members can be contacted to assess the occurrence of falls after applying the intervention in nursing practice. A reduction in the number of fall from previous statistics will be an indicator of the efficiency of the project. In addition, feedback can be gained from the patients or their service user regarding their service experiences. A positive feedback will indicate an improved clinical practice. Further, feedback can be sought from different professionals working closely with the nurses or their leader to evaluate their performances. To check the progress of the intervention and assess whether the nurses feel that the intervention is helping them in improving their practices, their attendances in weekly meetings and sessions can be checked. A decline in attendance will indicate lack of interest while consistent attendance will indicate that nurses are experiencing helpful outcomes in their practice through this project.
ACSQHC. (2017). National Model Clinical Governance Framework. Sydney: Australian Commission on Safety and Quality in Health Care.
Akyol, A. D. (2007). Falls in the elderly: what can be done? Int Nurs Rev., 54(2), 191-6.
Chang, Morton, Rubenstein, Mojica, Maglione, Suttorp, . . . Shekelle. (2004). Interventions for the prevention of falls in older adults: systematic review and meta-analysis of randomised clinical trials. BMJ, 328(7441).
Cuevas-Trisan. (2017). Balance Problems and Fall Risks in the Elderly. Phys Med Rehabil Clin N Am, 28(4), 727-737.
Gillespie, Robertson, Gillespie, Sherrington, Gates, Clemson, & Lamb. (2012). Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev, 12(9).
Hughes, R. G. (2008). Tools and Strategies for Quality Improvement and Patient Safety. In Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US).
Lee, A., Lee, K.-W., & Khang, P. (2013). Preventing Falls in the Geriatric Population. Perm J, 17(4), 37-39.
Luk, Chan, & Chan. (2015). Falls prevention in the elderly: translating evidence into practice. Hong Kong Med J, 21(2), 165-71.
Park, S. H. (2018). Tools for assessing fall risk in the elderly: a systematic review and meta-analysis. Aging Clin Exp Res., 30(1), 1-16.
Shi, & Chunhu. (2014). Interventions for Preventing Falls in Older People in Care Facilities and Hospitals. Orthopaedic Nursing, 33(1), 48-49.