Changing to a More Responsive Fall Prevention Plan for Older Persons

Patient Safety Against Injurious Falls Description A White-Paper Testimony on Current Risks With more than a thousand preventable deaths a day, the need to pay greater attention to improving current patient safety conditions and standards is unquestionable (Gandhi, 2014). This was the gist of a testimony to the U.S. Senate Committee on Health, Labor, Education and Pensions Subcommittee on Primary Health and Aging. The white paper discussed the current safety risks faced by ambulatory patients in the hospital setting.

This has been the direction of the patient safety movement since 15 years with emphasis on ambulatory safety problems. Recent studies identified the major safety issues confronting hospital settings. These include medication safety, missed or delayed diagnoses, transitions of care, patients' non-adherence to medication (Gandhi) and poor clinician communication with patients (Schnall et al., 2012). The last issue was the finding of a recent survey of 162 registered nurses attending an APN education program.

This issue accounted for 42.4% or almost of 489 encounters they had and relating to diagnosis or management or treatment of patients (Schnall et al.). But one more major current nursing practice, which cries out for prompt change, involves the management of injurious falls among patients. Insufficiency and Ineffectiveness of Current Programs (add Malik and Patterson, 2012) Why the Need for Change One out of three of hospitalized patients aged 65 and older suffer from falls (Malik, 2012).

The rate is highest among psychiatric or behavioral health facilities where it rises to a range of 4.5 to 25 incidents per 1,000 days (Malik). The aging population continues to swell not only nationally but also globally. With a third of them hospitalized and suffering from falls, often injurious, the need to change current preventive management measures to reduce the incidence and prevalence. (Add info from filler) B.

Key Stakeholders -- Older adults are the main key stakeholders, the one most affected as they are the victims of injurious falls and most in need of effective or improved prevention measures (Lach, 2011). Other Key Stakeholders and Their Roles They need the support of other key stakeholders, who are the informal caregivers, healthcare providers, and community groups (Lach, 2011). The informal caregivers are their families and those directly caring for them at home or in the hospital. The healthcare providers are the nurses, physicians, and hospital staff.

And community groups extend material, emotional, spiritual and other forms of outside support to these older adults and other stakeholders (Lach). C. Evidence Critique Table 1. Authors and Focus of Intervention -- R. Schnall et al.

patient safety issues Study Design or Method -- online survey project Intervention Settings and Populations -- 162 registered nurse enrolled at an APN education program Outcomes/Measures -- Most common were clinician communication problems with patients at 42.4% of 489 encounters Findings and Conclusions -- Improving or reducing these identified patient safety issues in APN practice setting may be accomplished through information technology. Evidence Strength -- Level 6 2. Authors and Focus of Intervention -- Sue Child et al.

factors influencing the implementation of fall prevention programs Study Design or Method -- systematic qualitative review of 19 literature from 1998-2012 synthesized through meta-etnography Intervention Settings and Populations -- community-dwelling older people and healthcare professionals Outcomes and Measures -- Limited data on barriers to implementation revealed practical considerations, adapting for community and psychological reasons. Implementation was also complex and influenced by several factors. Findings and Conclusions -- This review of various interventions showed substantial methodological issues, which deter the implementation of practice.

This systematic review recommended that those involved modify existing behavior, thoughts and practice and to fully consider and address the issues identified. Evidence Strength -- Level 5 3.

Authors and Focus of Intervention -- Angela Malik and Norma Patterson Preventing Falls in Acute Mental Health Settings Study Design or Method -- research article Intervention Settings and Populations -- older patients in an inpatient acute mental health setting Outcomes and Measures -- The article lists the factors, which lead to falls, and discusses how to prevent them in older adults I this health setting Findings and Conclusions -- Factors that contribute to falls in mental health settings can be intrinsic, extrinsic, situational or any two of these.

Prevention of falls and patient safety committees should combine their resources to reduce incidence. Fall prevention toolkits and evidence-based practices yield the causes of falls and how to prevent them, specifically in older adults in this setting. Strength of Evidence -- Level 5 4. Authors and Focus of Intervention - Lach, H.M. et al.

Best Practice in Fall Prevention and the Roles of Stakeholders Study Design or Method -- peer-reviewed article Intervention Setting or Population -- Older adults and other key stakeholders Outcomes or Measures -- Older adults are the key stakeholders in fall prevention. But the support of other stakeholders, like informal caregivers, healthcare providers and community groups is a basic requirement to prevention. Findings and Conclusion -- The roles played by additional stakeholders provide and make up the best practices in fall prevention.

They can help older adults help themselves avoid falls according to their individual preferences, available local resources, programs and healthcare services. Strength of Evidence -- Level 7 5. Authors and Focus of Intervention -- Wilson, D. et al.

Differences in Perceptions between Charge and Non-charge Nurses on Patient Safety Study Design or Method -- a descriptive correlational and cross-sectional study Intervention Settings or Populations -- 710 registered nurses at the 12 adult medical units of a large medical center in the Midwest Outcomes or Measures -- The differences between the perceptions of these two groups emanate from the broader view by charge nurses of both potential and real safety errors and greater familiarity with error reporting or errors in the unit than non-charge nurses.

Findings and Conclusion -- The differences in perceptions are quite important to patient safety, particularly in the assessment aspect, and in improving nurse effectiveness. The association between safety guidelines and nurse perceptions should be the subject of future study. Strength of Evidence -- Level 4 D. Summary of Evidence from Findings Malik and Patterson (2012) list the four types of factors, which can lead to falls in mental health settings, and explain each of them. These are intrinsic, extrinsic, situational and a combination of any two.

They suggest interventions in the form of engineering concepts and a system approach, identifying barriers, tracking and a review of all falls on a yearly basis. They recommend the assimilation of resources by fall prevention and patient safety committees and the use of tool kits and evidence-based practices specifically for older adults in hospital settings. The strength of evidence is B. As the evidence is of limited quality and drawn only from patient-oriented sources.

Child and her team (2012) used a systematic qualitative review of 19 literature sources from 1998 to 2012 in identifying the factors, which influence the successful implementation of fall prevention programs. These were records of community-dwelling older people and healthcare professionals. Their review yielded limited information, which included barriers to implementation and its complexities in methodology. They recommended a change in existing behavior, thinking and practice and a full address of the issues found. Schnall and team (2012) conducted an online survey project on patient safety issues with 162 registered nurses at an APN education program.

The survey revealed that the most common patient safety issue among the volunteer nurses was poor communication between clinicians and patients at 42.4% out of 489 encounters between them. The survey concluded that closing the communication gap between the two groups through the use of information technology would improve the situation (Schnall). Lach and her team (2011) pooled in and published their collective expert opinions in this peer-reviewed journal. They identify the key stakeholders in the prevention of falls, with older adults as the main or key ones.

But older adults stand in complete need of, and dependence on, the support of the rest of the identified key stakeholders. These are informal caregivers, like family members, relatives, friends, neighbors and other unrelated individuals; healthcare providers; and community groups. They describe the roles of these individuals and groups assisting older adults increase their own ability to prevent falls.

This assistance depends on target older adults' preferences, available resources, and outside programs and healthcare services (Lach et al.) Older adults are the key stakeholders in fall prevention programs as the very target recipient (Lach et al., 2011). Other key stakeholders are informal caregivers, such as family members, relatives, friends, neighbors and other helpful individuals; healthcare providers, like physicians, nurses, and other members of the healthcare team and paramedical staff; and community groups with programs and resources available for older adults.

The effective pool of efforts and resources of these support givers would constitute best practice (Lach et al.). Wilson and her team (2012) explore the differences in the perceptions of charge and non-charge nurses as essential in the implementation of patient safety policies and programs. Staff or charge nurses are employed to function as champions of change. They have more positive perceptions of safety than non-charge nurses. The authors further observed that the perceptions of charge nurses themselves are not uniform.

The length of experience in years, their view of team work within units, perception of safety, safety conditions of their work area, and the number of reported events in the immediate past month influence their perceptions of patient safety. These differences will strongly affect the effectiveness of a fall prevention program and overall patient safety culture in the hospital setting. E.

Recommended Best Practice according to the Findings Lach and her team recommend (2011) the identification of the key stakeholders and their respective roles and the execution of these separate roles in concert. These would institute the change needed to improve currently ineffective patient safety, specifically the prevention of falls among older adults. Best practice puts older adults at the center as the key stakeholders as the target recipients of the change in currently ineffective fall prevention initiatives.

But surrounding him are the other key stakeholders who support them by fulfilling their respective roles in the best-practice change initiative. Informal caregivers include family members, relatives, friends, neighbors and other individuals who informally assist these older adults or teach them ways of avoiding falls. Healthcare providers extend medical or paramedical treatment needed by these older adults. And community groups create and conduct fall prevention programs specifically for this vulnerable sector.

The assistance that these support groups can extend or provide for older adults will depend on these target individuals' preferences, available resources, healthcare services and the types of community programs that are operational or to be created to prevent falls and enhance patient safety in general. F. Best Practice Model A Practical Support for Fall Prevention The central implementers of this model are occupational therapists (Ballinger & Brooks, 2013). Older adults who are vulnerable to falls, especially those living in communities, are best helped physically by occupational therapists (Ballinger & Brooks).

The emphasis of this model is community life in that about 30% of this vulnerable sector who lives in a community suffers from falls every year (Ballinger & Brooks, 2013). Recent statistics say that less than 10% of them suffer from fractures but one out of five require medical treatment. In addition to these consequences, surviving fall victims also suffer from the fear of falling again, limit their daily activities and their enjoyment of life itself, and require admission to some form of support accommodation.

The prevention of falls has, therefore, been viewed as a high health priority globally (Ballister & Brooks). Older adults who are vulnerable to falls generally need a combination of regular strength and balance exercises and an adjustment of their environment in minimizing risks of falls (Ballister & Brooks, 2013). This model blends the person with his environment and activity. It suggests that these three components constantly interact and vary. The constant interaction and change allow the person the widest capacity for performance and function.

The greater the coordination among these three components, the better the person's performance becomes. Occupational therapists are trained to form a total and holistic view of a patient's situation. From there, they work with him while considering the factors in each of these components and how they interact (Ballister and Brooks). Scientific literature in the last decade reveals that physical exercises have been the approach in promoting strength and balance (Ballister & Brooks, 2013).

This approach has placed occupational therapists at center stage in helping individuals perform their activities and occupations more capably. Occupational therapists are of specific value to older persons who are falls-vulnerable by building their self-efficacy skills in performing daily activities without falling. These therapists also play an important role in looking into older people's fear of falling and in preventing them. They can discuss workable means or strategies of improving older people's confidence and teach as well as help them implement these strategies (Ballister & Brooks).

Most of these older persons do not know about these fall prevention strategies (Ballister & Brooks, 2013). Educating them on these strategies is a prime responsibility of occupational therapists. Occupational therapists are currently taking advantage of the convenience and versatility of information technology in making the knowledge of these strategies as widely available as possible and to the vulnerable sectors, older people in particular (Ballister & Brooks). As earlier described, the implementation of this model addresses the three elements of personal, environmental and activity.

The Personal Element This consists of physical exercises meant to help fall-prone older persons perform their daily or chosen activities and occupations (Ballister & Brook, 2013). Two falls prevention programs have been in use, one intended for use at home, and the other, as a group exercise. One possible problem that therapists encounter in an exercise program is older persons' difficulty in adhering to exercise. Experts developed an approach, which integrates strength and balance training into older persons' daily routines and activities.

The integration was found effective as an exercise intervention measure and as a fall preventive. Websites also became available to the general public, including older persons, with personalized advice on the benefits of exercise for fall prevention (Ballister & Brooks). The Environmental Element This covers home safety, communication aids, vision correction or enhancement, and adjustment of footwear (Ballister & Brooks, 2013). Tools that may be used to implement this element include home falls and accidents screening tools and safety assessment.

This element also imparts the relationship between older people, outdoor falls, and the design of the outdoor as well as the identification of potential spots for falls (Ballister & Brooks). The Occupation Element This element covers older persons' daily activities and how they can perform them safely and how to find opportunities for greater participation in activity (Ballister & Brooks, 2013). There are standardized occupational therapy assessment tools, which evaluate a person's performance of daily activity of their choice. Examples are preparing their own food and making their own bed.

In some cases, these tools may be in the form of adaptive equipment for seats or bath or night light. These tools are definitely cheaper than the cost of a hip fracture surgery (Ballister & Brooks). Multiple-Risk Element Intervention An example in use is the Stepping On Program, based on Bandura's social learning theory (Ballister & Brooks, 2013). This combines exercise and home safety intervention and education. It targets falls self-efficacy and adult learning principles.

Randomized controlled trials provided evidence that this program can reduce the incidence of falls by 31% (Ballister & Brooks). Forthcoming Approaches A pilot study is currently being undertaken by occupational therapists for falls prevention of older persons with visual defects and damage (Ballister & Brooks, 2013). They are also looking into the feasibility of translating information materials on general falls prevention for older persons with cognitive disabilities. Virtually all the needs and challenges confronted by impaired individuals, especially actual and potential victims of falls, will make the contributions of occupational therapy valuable.

Hence, it keeps growing (Ballister & Brooks). G. Barriers to the Proposed Change A major obstacle to the implementation of this or any other model of fall prevention for older persons is the diverse perceptions among them, their families and healthcare professionals (Child et al., 2012), Besides differences in perceptions, there also exist tensions among them on the balance of power, expertise, and the matter of independent relationship between older persons and their families, they and healthcare professionals.

Some of these older persons may accept their increased risk of falls as a sign of advancing age, reduced competence and independence. That perception cannot prevent the occurrence of falls. The view is fatalistic and a strong barrier to the desired change in programs or policy. If they are convinced and adamant that they have little control over what happens to them, they are unlikely to cooperate with any effort at engaging and cooperating with any prevention mechanism or goal. Others may outright reject interventions from stereotypes of their frailty.

But the rest may appreciate interventions, which will give them the opportunity to expand social contact with those their age and ability (Child et al.). Barriers to the successful implementation of a change in fall-prevention practices can be present in or among older persons themselves, healthcare professionals and healthcare systems themselves (Child et al., 2012). Improving or insuring that change in current practices should take into serious consideration individual beliefs and behaviors, and those in the organizational and societal levels.

A practical approach to eliminating barriers may be consulting with older persons in order to determine the changes they are ready and willing to participate in or cooperate with in order to minimize their risk of falls. This consultation cannot be overlooked in undertaking the desired or intended change. It has been said that there is more work to be done on patients' views and preferences than are contained by evidence-based recommendations (Child et al.).

Other barriers already recognized are poor clinician-patient communication, poor or low staff training, inadequate patient education, the environment and the lack of appropriate equipment (Malik & Patterson, 2012). Occupational therapy also noted the perception of some older persons that falls prevention services designed for them actually compromise their sense of self and dignity (Ballister & Brooks, 2013). H. Ethical Implications to Implementing the Change Ethics to the elderly does not always mean the same as it does to their families or healthcare providers (Ensign, 2008).

Family members as caregivers see ethics as doing what is right even when no one imposes it or is looking or listening. Healthcare professionals view ethics as observing a Code of Ethics to which they have been formally sworn as members of the recognized association of physicians, nurses and social workers. But older persons see or interpret ethics as the way they think they should be treated. It includes being allowed to make their own decision and doing what they want to do.

The most common ethical issues encountered by caregivers of older persons are actual conflicts of interest, potential future or perceived conflicts of interest, confidentiality and decision-making capacity. All these relate to the conditions of older people, including even desirable changes in a fall prevention strategy or program (Ensign). Actual conflicts may be between the older person's wishes and those of spouses, of other family members of different generations, guardians, and the caregiver's business interests and the older person's welfare and quality of life (Ensign, 2008).

Conflicts may also be merely potential or perceived but may become actual according to the development of events. Social workers are trained to handle potential conflicts in families (Ensign). Principlism appears to be the ethical framework, which guides elder caregivers in making decisions and in other encounters in their work (Ensign, 2008). This frame takes into serious consideration the human basis of all aspects of healthcare and all actions that emanate from it.

It extends to a determination and an understanding of the situation of the patient and the respect due him or her, according to essential ethical principles. Elder caregivers apply this ethical framework for the benefit of their patient's overall well-being and in improving the quality of their lives. This framework is especially pertinent when the patient's capacity to make sound or logical decisions has become less than normal. The four essential principles are autonomy, beneficence, nonmaleficence, and justice (Ensign).

The Ethical Issue of Autonomy This equates to the older person's own choices, both.