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Evidence Based Nursing Practice 

Introduction to ICT-Based Fall Prevention System

Watson (2011) defines nursing as a school of thought and science of taking care. She argues that students should study Caring Science in the beginning when they take up nursing as a field of study, because it lays the foundations of ethics, morals and values. These disciplinary foundations help the student in her or his job as a nurse in the long run. They help the student in finding the true meaning of humanity and being human as an important part of the universe. The procedures involving collecting, processing and applying the research findings for the improvement of clinical practice, the environment of work or the outcomes in patients, is called evidence-based practice (EBP) (Chrisman, et. al., 2014). It starts from knowing about what symptoms the patient is having, recognising the disease and ends at administering the appropriate medication to the patient. EBP in nursing is of high quality and most cost-effective. The chosen scenario for this assessment is increase in the number of falls among the elderly in an aged care home over the last one year and the research method used in this case study is the 5A’s EBP approach.

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The research question is “Using EBP reference models in reducing the number of falls among the elderly”. Being a student of nursing and a professional who attends clinical placement at an aged care home, a person is expected to know everything in detail about the health problems facing the elderlies, when their symptoms develop, how to diagnose the problem or disease and what should be the best course of action to be taken to treat the problem or disease. A professional at an aged care home is expected to be an expert in geriatric care. She or he cannot become an expert in their field unless they ask the right questions related to their field, in this case, geriatric care. This research question is correct, direct and precise. Had the question been “Measures to take to reduce the number of falls among the older patients”, it would have been more indirect and would have led the Nurse Unit Manager to have shifted from the core issue itself in answering the question.

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Thomas, et al. (2012) have put a great deal of emphasis on the creation of an EBP reference model in falls prevention. Their study was attempted to explore EBP efforts among expert occupational therapy (OT) clinicians so that an EBP reference model in falls prevention could be evolved. The findings were that clinicians do not specialise in EBP. Mostly, the bases of their decisions are experience and evidences from past researches. Aberg, et al. (2009) came up with a “fall prevention pyramid model” as a multifactorial and multi-professional fall prevention intervention. The model includes general, individual-specific and serious case interventions. Recording events of falls and following up on them are emphasised as crucial parts of local learning and improvement of safety. They pointed out that a well-formed mechanism for patients’ safety which focuses on fall prevention will, be viewed by the staff, patients and other people as an important aspect of the organisation and will be apparent in its outlooks, routines and measures. Wexler and D’Amico (2015) have highlighted that falls are amongst the major concerns for elderly people in all kinds of environments. It can happen due to disease or cause the same, it can cause death or a significant damage to the person’s quality of life. According to Wexler and D’Amico, the Iowa model of EBP can be implemented in these cases. It can be easily understood and used and is trustworthy. The approach of this model is a systematic one. An in-depth analysis of the problem, in this case, falls, is first done and then research is gathered to recognize practical actions to tackle it. The previous practices are altered or modified to lessen the recurrence of the problem. The records of the most recent falls can be accessed and analysed, post which some action plans can be formulated which are evaluated by an interdisciplinary team. After the review, the action plans can be implemented in the organisation. Lee, et al. (2013) have recommended that clinicians should ask about falls history of on year of the older adults. They have also recommended the Timed Up and Go Test which involves timing and observing an older person from the moment she or he is sitting back relaxed in an arm chair, stands up, walks three meters, turns around, walks back up to the chair and sits back down in the same relaxed position. The interventions they have pointed out are withdrawal or minimization of psychoactive medications, managing orthostatic hypotension, managing foot problems and expedited cataract surgery and dual chamber cardiac pacing for selected patients. Guirguis-Blake, et al. (2018) have highlighted the importance of multifactorial interventions like fall risk assessment, exercise and Vitamin D supplementation among older adults to reduce fall rates. Myers (2015) has suggested some practical ways to prevent falls among the elderlies. Installation of grab bars and handrails can help the elderly navigate the spaces with ease, comfort and without the risk of falling. Convincing the elderlies not to wear loose-fitted clothes can prevent them from tripping over their own pyjamas. The areas open to access for the elderlies should be well-lighted. They tend to fall by hitting with objects in dark spaces. Making the elderlies wear shoes can also prevent them from slipping or falling as shoes have a tight grip in their soles. Moncada and Mire (2015) have suggested that balancing exercises and physical therapy can help preventing falls in the elderly. The have also suggested that older people should take Vitamin D3 supplements of at least 800 IU daily to strengthen their bones. They should obtain multifactorial risk assessments and interventions. Benzodiazepines and other sedative-hypnotics should not be considered as the first choice for treating elderlies with insomnia or agitation. For those older adults who are visually impaired, removal of extra clutter as a modification of home environment can help in reducing their falls.

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Phelan, et al. (2016) have pointed out that EBP reference models to prevent falls in older adults are not practically implemented in clinical practice. They found from among their subjects that most of the falls occur due to the lack of Vitamin D in their bodies. The other two factors were strong medication and lack of home safety measures. Vind, et al. (2009) have pointed out that multifactorial fall prevention interventions do not have any effects on elderly outpatients. They stress instead on identifying the general medical conditions, cardiovascular disease and other physical risks among the elderly. The study concluded that multifactorial fall prevention interventions did not yield successful results in attempts to prevent further falls. Melin (2018) had used the Iowa model of EBP to improve the quality of a project undertaken to reduce fall rates among the inpatients in a hospital setting. Before starting off with the project, a training in falls education using an altered pre-existing fall checking procedure was given to the hospital staff. The patients were encouraged to increase the use of their bedside or chair alarm in case they feel they are about to fall. The result was 44.5% decrease in fall rates per month postintervention, thus signifying that education of the staff and the use of alarms by the elderly can be effective in EBP for fall prevention. Bischoff-Ferrari, et al. (2009) in their research concluded that a dose of 700-1000 IU of Vitamin D or supplemental Vitamin D per day can reduce the possibility of falls in old people by at least 19%.

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Naseri, et al. (2020) have discovered that fall prevention education of carers and patients can reduce fall rates. Access to therapy and social support also brings about improvement in fall confidence of older adults. Ayton, et al. (2017) have identified some enablers to fall prevention programs. These are older people believing that falls can be prevented, imparting education and training to both older adults and their caregivers, regular supply of resources like medication and required equipment like balancing kits. EBP and data-driven practice were also identified as enablers. Vlaeyen, et al. (2017) found, among eight relevant studies they referred to, 44 determinants influencing the implementation of EBP in preventing falls among older adults. 17 of these determinants were facilitators to prevention and 27 were barriers to fall prevention. Some facilitators found were regular interaction with the elderly and good equipment at their disposal. The barriers identified were frustrated staff and staffing issues, limited knowledge and skills in fall management and lack of regular interaction with the elderly. They have stressed that multifactorial interventions which work on the fall risk profiles of elderly individuals, are indispensable to successful fall prevention programs. Koh, et al. (2008) have highlighted lack of knowledge and incentive, accessibility of staff for support, access to facilities and patients’ poor health as the main barriers to fall prevention programs. Child, et al. (2012) have observed that the established practices and thoughts need to be modified to successfully implement a fall prevention program. Bunn, et al. (2008) have described social support, mild exercises, good education and participative decision-making as facilitators to fall prevention programs. National Institute of Aging (NIA) (n.d.) suggests that facilitators to prevent falling are getting one’s eyes and ears tested, finding out about the side effects of the medication one is prescribed, getting enough sleep, using assistive devices like handrails, wearing shoes and letting one’s doctor know about one’s fall history. NIA has also suggested that giving enough calcium and Vitamin D to one’s body and quitting unhealthy habits like smoking, drinking or any other form of intoxication, also act as facilitators to fall prevention.

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Colon-Emeric, et al. (2013) committed to engaging and interacting heavily with older patients in nursing homes through their control and/or intervention programs. The control programs were of three months’ duration and the intervention programs were of six months. The staff of the nursing homes was also included in the program and educated and trained in fall management and communication skills. It was observed that good communication with the older patients and making them a part of decision-making helped in reducing the rate of falls at the intervention centres. However, little or no change was observed in the control centres. Ogonowski, et al. (2016) have highlighted that education in health, both for clinical staff and older patients, constant monitoring, enhanced technical know-how and a good quality of life has helped in preventing falls among older adults. Moreover, mild exercises, breathing and balancing exercises, sufficient intake of Vitamin D, use of handrails and wearing shoes and fitting clothes have also prevented falls among older adults. Anders, et al. (2007) have identified that training sessions of clinical staff and nurses greatly helped reduce fall rates. Vaziri, et al. (2016) have suggested that motivation and inspiration are also factors which helped in reducing fall rates.

Conclusion on ICT-Based Fall Prevention System

It can be concluded that people in their old age are at the risk of falling due to a variety of reasons like personal inhibitions about walking, medicinal side-effects, poor health, weak bones, lack of nutrition, poor infrastructure in their dwellings, loss of vision or hearing and dark spaces among many others. There are many evidence-based practice (EBP) models to choose from which help in formulating action plans as to how interventions should be introduced to reduce fall rates among elderly people, whether they live at home, in aged home care facilities or are inpatients in hospitals. The most important thing to note from this case study is that the clinical staff taking care of these aged individuals as well as the aged individuals themselves, should be well-educated and well-trained in the domains of effective communication and fall management. Old people must take the minimum required dose of Vitamin D daily and perform mild exercises to have a good health and sustain themselves.

References for ICT-Based Fall Prevention System

Åberg, A. C., Lundin-Olsson, L., & Rosendahl, E. (2009). Implementation of evidence-based prevention of falls in rehabilitation units: a staff's interactive approach. Journal of Rehabilitation Medicine41(13), 1034-1040. DOI: https://doi.org/10.2340/16501977-0452

Anders, J., Dapp, U., Laub, S., & von Renteln-Kruse, W. (2007). Impact of fall risk and fear of falling on mobility of independently living senior citizens transitioning to frailty: screening results concerning fall prevention in the community. Zeitschrift fur Gerontologie und Geriatrie40(4), 255-267. DOI: 10.1007/s00391-007-0473-z 

Ayton, D. R., Barker, A. L., Morello, R. T., Brand, C. A., Talevski, J., Landgren, F. S., Melhem, M. M., Bian, E., Brauer, S. G., Hill, K. D., Botti, M. & Livingston, P. M. (2017). Barriers and enablers to the implementation of the 6-PACK falls prevention program: A pre-implementation study in hospitals participating in a cluster randomised controlled trial. PloS one12(2), e0171932. DOI: https://doi.org/10.1371/journal.pone.0171932

Bischoff-Ferrari, H. A., Dawson-Hughes, B., Staehelin, H. B., Orav, J. E., Stuck, A. E., Theiler, R., ... & Henschkowski, J. (2009). Fall prevention with supplemental and active forms of vitamin D: a meta-analysis of randomised controlled trials. Bmj339, b3692. DOI: https://doi.org/10.1136/bmj.b3692

Bunn, F., Dickinson, A., Barnett-Page, E., Mcinnes, E., & Horton, K. (2008). A systematic review of older people's perceptions of facilitators and barriers to participation in falls-prevention interventions. Ageing & Society28(4), 449-472. DOI: https://doi.org/10.1017/S0144686X07006861

Child, S., Goodwin, V., Garside, R., Jones-Hughes, T., Boddy, K., & Stein, K. (2012). Factors influencing the implementation of fall-prevention programmes: a systematic review and synthesis of qualitative studies. Implementation science7(1), 91. DOI: https://doi.org/10.1186/1748-5908-7-91

Chrisman, J., Jordan, R., Davis, C., & Williams, W. (2014). Exploring evidence-based practice research. Nursing Made Incredibly Easy12(4), 8-12. DOI: 10.1097/01.NME.0000450295.93626.e7

Colon‐Emeric, C. S., McConnell, E., Pinheiro, S. O., Corazzini, K., Porter, K., Earp, K. M., ... & Anderson, R. A. (2013). CONNECT for better fall prevention in nursing homes: results from a pilot intervention study. Journal of the American Geriatrics Society61(12), 2150-2159. DOI: https://doi.org/10.1111/jgs.12550

Guirguis-Blake, J. M., Michael, Y. L., Perdue, L. A., Coppola, E. L., & Beil, T. L. (2018). Interventions to prevent falls in older adults: updated evidence report and systematic review for the US Preventive Services Task Force. Jama319(16), 1705-1716. DOI: 10.1001/jama.2017.21962

Koh, S. S., Manias, E., Hutchinson, A. M., Donath, S., & Johnston, L. (2008). Nurses' perceived barriers to the implementation of a Fall Prevention Clinical Practice Guideline in Singapore hospitals. BMC health services research8(1), 105. DOI: https://doi.org/10.1186/1472-6963-8-105

Lee, A., Lee, K. W., & Khang, P. (2013). Preventing falls in the geriatric population. The Permanente Journal17(4), 37. DOI: 10.7812/TPP/12-119

Melin, C. M. (2018). Reducing falls in the inpatient hospital setting. International journal of evidence-based healthcare16(1), 25-31. DOI: https://doi.org/10.1097/XEB.0000000000000115

Moncada, L. V. V., & Mire, L. G. (2017). Preventing falls in older persons. American Family Physician, 96(4), 240-247. Retrieved, September 5, 2020, from: https://www.aafp.org/afp/2017/0815/p240.html

Myers, W. (2015). 9 ways to prevent falling at home. Retrieved, September 5, 2020, from: https://www.everydayhealth.com/longevity/future-planning/prevent-falls-at-home.aspx

Naseri, C., McPhail, S. M., Haines, T. P., Morris, M. E., Shorr, R., Etherton‐Beer, C., Netto, J., Flicker, L., Bulsara, M., Lee, D. A., Waldron, N., Boudville, A., Hill, A. & Francis‐Coad, J. (2020). Perspectives of older adults regarding barriers and enablers to engaging in fall prevention activities after hospital discharge. Health & Social Care in the Community. Retrieved, September 6, 2020, from: https://onlinelibrary.wiley.com/doi/abs/10.1111/hsc.12996

National Institute of Aging. (n.d.). Prevent falls and fractures. Retrieved, September 5, 2020, from: https://www.nia.nih.gov/health/prevent-falls-and-fractures

Ogonowski, C., Aal, K., Vaziri, D., Rekowski, T. V., Randall, D., Schreiber, D., ... & Wulf, V. (2016). ICT-based fall prevention system for older adults: qualitative results from a long-term field study. ACM Transactions on Computer-Human Interaction (TOCHI)23(5), 1-33. DOI: https://doi.org/10.1145/2967102

Phelan, E. A., Aerts, S., Dowler, D., Eckstrom, E., & Casey, C. M. (2016). Adoption of evidence-based fall prevention practices in primary care for older adults with a history of falls. Frontiers in public health4, 190. DOI: https://doi.org/10.3389/fpubh.2016.00190

Thomas, A., Saroyan, A., & Lajoie, S. P. (2012). Creation of an evidence-based practice reference model in falls prevention: Findings from occupational therapy. Disability and rehabilitation34(4), 311-328. DOI: https://doi.org/10.3109/09638288.2011.607210

Vaziri, D. D., Aal, K., Ogonowski, C., Von Rekowski, T., Kroll, M., Marston, H. R., Poveda, R., Gschwind, Y. J., Delbaere, K., Wieching, R. & Wulf, V. (2016). Exploring user experience and technology acceptance for a fall prevention system: results from a randomized clinical trial and a living lab. European review of aging and physical activity13(1), 6. DOI: https://doi.org/10.1186/s11556-016-0165-z

Vind, A. B., Andersen, H. E., Pedersen, K. D., Jørgensen, T., & Schwarz, P. (2009). An outpatient multifactorial falls prevention intervention does not reduce falls in high‐risk elderly Danes. Journal of the American Geriatrics Society57(6), 971-977. DOI: https://doi.org/10.1111/j.1532-5415.2009.02270.x

Vlaeyen, E., Stas, J., Leysens, G., Van der Elst, E., Janssens, E., Dejaeger, E., ... & Milisen, K. (2017). Implementation of fall prevention in residential care facilities: A systematic review of barriers and facilitators. International journal of nursing studies70, 110-121. DOI: https://doi.org/10.1016/j.ijnurstu.2017.02.002

Watson, J. (2011). Nursing. Colorado: University Press of Colorado.

Wexler, S. S., & D’Amico, C. O. N. (2015). Creating an environment of falls prevention. American Nurse Today10(7), 34-35. Retrieved, September 5, 2020, from: https://www.myamericannurse.com/wp-content/uploads/2015/07/ant7-Falls-630_Creating.pdf

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