HCA 620 Capstone Project Proposal

HCA 620 Capstone Project Proposal

HCA 620 Capstone Project Proposal

Abstract

The practice of nursing in the modern world is highly influenced by the utilization of evidence-based practice. Nurses are involved in the constant search for the best available evidence that can be used to enhance the health outcomes of their patients. Successful use of evidence-based practice demands that organizations create enabling environments. The management should be willing to support initiatives that ensure that nurses engage in critical appraisal of existing evidence and their use in clinical practice. Evidence-based practice can be utilized in the management of different health problems. Therefore, this paper is a proposal of evidence-based practice that should be adopted to reduce or prevent patient falls. Accordingly, current evidence indicates that patient falls is a critical health issue facing patients, healthcare providers and healthcare institutions as a whole. Patient falls predispose the patients to injuries that reduce their functional abilities and increase their hospital stay. It also increases the costs incurred by patients in seeking the care they need.

Several interventions have been adopted to address the issue of patient falls in the clinical settings. One of them is the use of call lights, which has proven ineffective in addressing the issue. As a result, the researchers believe that the adoption of nursing rounds in the clinical settings is an effective method that can help to prevent and reduce patient falls. Moderate evidence of the efficacy of this intervention exists. Successful implementation of the intervention will be achieved with the use of innovations diffusion theory. The setting of implementation of the intervention will be medical units at Hospital X where one ward will be administered with the intervention while the other will entail the use of call lights for prevention and reduction of patient falls. The intervention will be evaluated based on the prevalence of patient falls and its associated injuries in the unit within the period of the intervention.

Capstone Project Proposal

Evidence-based practice has significantly transformed the nursing care that is provided to patients in both clinical and community settings. It has resulted in the improvement in quality, safety, and efficiency of care provision to those in need. The improvement is attributed to the increased focus on the use of best-available clinically significant data to enhance patient and care outcomes. It is therefore the responsibility of the nurses and other healthcare providers to ensure that evidence-based practice is utilized in assessing and intervening on matters related to the healthcare needs of the vulnerable populations. Consequently, this research proposes the utilization of nursing rounds to reduce future risk of falls among patients in medical surgical units in comparison with the use of call lights.

Problem Description

Falls among patients admitted in the clinical settings are one of the major concerns for the patient, healthcare providers and institutions of healthcare as a whole. It often results in undesired health outcomes that include disability, longstanding pain, premature hospital admission, functional impairment, and increase in the duration of hospital stays and mortalities. Statistics presented by King et al. (2016) indicates that the average rates of falls among patients in the clinical setting vary from three to 17.1 falls in every 1000 bed days. It is also estimated that about one to five patients who are admitted in inpatient rehabilitation units will fall at least once during their period of stay in the unit. The prevalence of falls in acute care hospitalizations has been shown to range between 1.9-3% (Pearson, Karen & Andrew, 2012). The falls can result in injuries in about 9-33% of these patients. As cited in Pearson et al., (2012), the Institute for Healthcare Improvement reports that falls is the leading cause of mortalities among patients aged above 65 years old, with 10% of them occurring in the hospital setting. Other than causing the above identified health problems, an occurrence of a fall in the clinical setting has also been shown to predispose patients to significant level of falling anxiety, depression, and distress, which reduces their level of physical activity (Leone & Adams, 2016). Falls among the patients also increases the patient and healthcare organizations spending on healthcare. As shown by Leone and Adams (2016), an occurrence of a fall can increase the costs incurred by patients by up to $13, 316.20. This cost can increase the overall healthcare spending by the patients by up to 60% when compared to any other patient hospitalized in an institution. Therefore, it is expected that the estimated cost associated with treating injuries from falls will rise to $54.9 billion by the year 2020 (Pearson et al., 2012).

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Several risk factors for patient falls exist in the clinical setting. One of them is age. Patients who are aged above 65

HCA 620 Capstone Project Proposal
HCA 620 Capstone Project Proposal

years old have been shown to be highly at risk of experiencing patient falls (King et al., 2016). The high risk among this patient cohort is attributed to factors such as confusion, walking limitation, and bladder incontinence that increases the need for mobility among them (Severo et al., 2018). The other risk factors identified by King et al., (2016) in their research include adverse drug reactions, neuro-cardiovascular instability, agitation, and gait instability. Adverse reactions, particularly those associated with psychotic medications, have been shown to increase the patient’s risk of falls (King et al., 2016; Hayakawa et al., 2014). Hospital factors such as the lack of fall prevention policy and absence of a healthcare provider have also been associated with increased risks of patient falls. There is also the evidence that patient’s health status and the frequency of medications within a given period increases the patient’s risk for falls. According to Severo et al., (2018), the risk of falls among patients during the post-operative period was significantly high. A high frequency of medications within 72 hours before a fall was also considered a risk factor for the problem among hospitalized patients in the study by Severo et al., (2018). Other risk factors as identified by Najafpour et al., (2019) in their research include long stay in the hospital, use of chemotherapy drugs, balance conditions, manual transfer of patients, and history of falls.

Nurses and other healthcare providers have a critical role to play in preventing falls among hospitalized patients. They have to explore the best available evidence that can be used to address the problem in their settings. They also have to advocate for the adoption of patient-friendly and safety policies that will reduce the prevalence of the problem in their setting. Interventions that include requiring patients to wear high-risk wristbands, medications review, bed signage, prescription of vitamin D, and provision of mobility aids have been reviewed for their efficacy in fall prevention (Morris & O’Riordan, 2017). However, evidence concerning the efficacy of these interventions in preventing fall prevalence in hospitalized patients remains inconclusive. Therefore, it is important that other interventions such as the use of regular nursing rounds are explored to inform evidence-based practice in prevention of falls among hospitalized patients.

Proposed Intervention

Due to the lack of conclusive evidence on the most effective intervention to prevent or reduce incidents of falls among hospitalized patients, this evidence-based practice paper proposes the use of nursing rounds over call lights in the prevention and reduction of falls among patients hospitalized in medical surgical unit. The PICO question is as follows:

For adult inpatients in medical surgical unit, does the use of nursing rounds reduce the future risk of falls when compared with call lights?

Literature Support

Literature that support the proposed research intervention for the evidence-based practice was obtained from the articles reviewed in Appendix B.  Six articles were included in the appraisal. It is worth noting that there is an acute shortage of evidence on the use of nursing rounds to reduce incidences of falls among hospitalized patients. This can be seen from the fact that a majority of the articles are systematic reviews, with one of them dated back to the year 2006. The appraisal of the research articles showed that there is moderate evidence on the efficacy of using nursing rounds to prevent or reduce prevalence of patient falls. The frequency of nursing rounds that were examined in these articles is hourly nursing rounds. While one article reported nursing rounds to be associated with outcomes that are not statistically significant, the findings have some clinical significance due to the duration of the study and the variables that were under investigation.

Mitchell et al., (2014) conducted a systematic review of literature that aimed at investigating the effect of nursing rounds on nursing responsiveness. The authors searched databases that included EMBASE, CINAHL, and Medline for studies on the topic. The outcomes of the review demonstrated that hourly nursing rounds have a significant effect on the satisfaction of patients with care, patient falls, and call light use. While this conclusion has impact on the proposed intervention, this research had low reliability due to the methods that were used. Firstly, the articles that were used in the review had considerable variability in their study protocols. They also had methodological bias, which lowered their significance. However, being among the few studies on the topic, the current study will rely on its conclusions on the efficacy of nursing rounds in preventing patient falls.

Goldsack et al., (2015) conducted a pilot study that aimed at examining the effect of hourly nursing rounds on patient falls. The study was conducted over a 30-day period in two units to determine the impact of the intervention on patient falls. The study utilized the support from nurse leaders, who acted as the champions for the intervention. The study outcomes from this research demonstrated significant efficacies in the use of nursing rounds to prevent or reduce patient falls. According to the outcomes, a decline in the patient fall rate in unit one by 3.9 falls per 1000 patient days was reported. There was also a decline in patient fall rate in the pilot period by 1.3 falls per 1000 patient days, which was lower than the predicted baseline fall rate. The fall rate in the second unit was 2.6 falls in every 1000 patient days.

However, the fall rate during the pilot period was not significant as evidenced by a fall rate of 2.5 falls per 1000 patient days from 2.6 falls per 1000 patient days. Therefore, the authors concluded that the use of nursing rounds is only effective if there is adequate interdisciplinary engagement as seen from the study findings from unit one. The study findings reported by Goldsack et al., (2015) can be relied wholly for this intervention. This can be seen in the reliability and validity of the methods that were used. The study period also allowed for the identification of any effect of intervening factors on the study variables.

Daniels (2016) conducted a study that aimed at examining the effect of purposeful as well as timely nursing round on patient safety and satisfaction. The intervention was implemented in the clinical setting where nursing rounds were done hourly to promote the outcome measures of the research. The study outcomes revealed that there was doubling of the intervals of nursing rounds during sleeping and awake hours. There was a substantial increase in compliance with the intervention up to 64% from zero. The outcomes included substantial increase in patient toileting by 41%, responsiveness of the staffs by 15% and reduction in patient falls by 50%. Therefore, the researchers recommended the use of purposeful as well as timely nursing rounds to promote patient safety in relation to aspects such as prevention of falls and improvement in staff responsiveness. The outcomes reported by Daniels (2016) in his study can be relied upon in the proposed intervention. This is attributed to the reliability and validity of the methods used in investigating the research topic.

The study conducted by Tucker et al., (2012) aimed at examining the feasibility of using structured nursing rounds interventions in preventing patient falls in practice. The researches utilized a repeated measures design where risk assessment and fall rates data were obtained over 12 week period and one year after the intervention was implemented. The results showed a significant decline in falls per 1000 hospital days with a considerable fall in the scores of mean fall risk assessment. However, these rates returned to baseline after one-year period. Therefore, the authors concluded that while the intervention might prove effective in reducing incidence of falls among patients, models that sustain the use of the intervention should be embraced. This study is associated with significant strengths. It has high research validity since the sample, methods of data collection and analysis, and observational procedures are explicitly explained. Consequently, it forms the basis of the proposed intervention for this evidence-based practice proposal.

The research by Meade, Bursell and Ketelsen (2006) investigated the effect of nursing rounds on patients’ satisfaction, safety, and call light use. The outcomes revealed that nursing rounds performed on specific intervals were associated with significant reduction in rates of patient falls and use of call lights and enhanced patient satisfaction rate. This study is associated with high reliability and validity. The intervention was implemented and its outcomes followed up for some time. The follow up allowed the researchers to explore possible intervening factors that might affect the outcomes of the study. The methods of variable analysis are also adequate as they pointed out the existing relationship with the outcomes of the research. The research by Walsh et al., (2018) showed that the use of multifaceted fall prevention intervention improved the trends of fall rates among hospitalized patients. The multifaceted program, which included the use of nursing rounds, showed that there was significant decline in patients’ falls and injuries due to the use of hourly rounds to mitigate risks of falls. Therefore, based on these sources of evidence, it proves apparent that the use of nursing rounds has enhanced efficacy when compared to call lights in prevention and reduction of falls among hospitalized patients.

Solution Description

It is evident that falls among hospitalized patients is an issue of concern to not only the patients but also healthcare stakeholders too. The use of interventions such as call lights, mobility devices, regular administration of vitamin D, and review of medications have been found to be ineffective in addressing the issue. As a result, further studies need to be conducted to bridge the gap in evidence related to this issue. Therefore, basing on the above literature, the researchers propose the use of nursing rounds in the medical surgical unit to reduce and prevent falls among hospitalized adults as opposed to the utilization of call lights. The intervention will be adopted by the nurses working in the unit. It will comprise of patients being divided into two groups and the treatment administered to one group and the other group used as the control. The treatment group will receive hourly nursing rounds while the control group will receive the normal nursing care characterized by the use of call lights. The intervention will be administered over eight month’s period. The outcome measure of interest will be the prevalence rate of patient falls and injuries in both groups of patients. Data will be obtained using observation and patient fall statistics. Data analysis will be done to provide insights into the efficacy of the intervention over call lights in the prevention and reduction of falls among hospitalized adults in the unit.

Change Model

The adoption of the intervention will be a change agent in itself. As a result, it will demand the adoption of a model that will facilitate its successful incorporation into the nursing practice. The researchers will utilize the diffusion innovation theory to introduce the intervention into the clinical practice in the unit. Everett Rogers developed the diffusion innovations theory with the aim of explaining the manner in which new technologies and ideas spread. The decision-making in this model occurs in five steps that include knowledge, persuasion, decision, implementation, and confirmation. The first stage of the model, knowledge, entails the adopters of the change being exposed to the agent. However, they do not have any knowledge related to the change agent. As a result, they are not inspired to learn more about the change agent and its potential effect on them. In relation to the proposed intervention, the nurses in the unit do not know that evidence-based approaches such as the use of nursing rounds to reduce or prevent falls among patients (Santacreu, 2015). Therefore, they are not inspired to explore alternatives that can be adopted to address the issue in their practice.

The second step of the model is persuasion. In this stage, the adopters are interested in the change agent. They begin to seek actively any information related to it. This stage is the learning stage where they explore the potential benefits as well as risks associated with the intervention. In relation to the proposed intervention, the nurses in the unit have now become aware of the need for a change in the prevention of patient falls in their setting. They explore the potential benefits as well as harms of nursing rounds in preventing or reducing patient falls (Santacreu, 2015). As a result, the researchers will increase the availability of sources of information to them to enhance their level of awareness and adoption process.

The third step in the model is decision-making. The adopters weigh the benefits as well as disadvantages of the change agent. They use their desires to determine whether they will adopt the agent or not. Therefore, it will be important for the researchers to ensure that they provide the adopters with the support they need to embrace the change. The fourth step in the model is implementation phase. This phase is characterized by individual adopting the change to a varying degree based on their situation. The adopters consider the usefulness of the intervention and might search for any further information about it. This will determine whether they move to the last step of the model or abandon the change agent. The last step of the diffusion innovations theory is confirmation. It is characterized by the adopters of the change agent finalizing their decision on embracing and the continued use of the change agent. The decisions at this stage are dependent on interpersonal or intrapersonal influences such as attitude towards the change agent (Santacreu, 2015). In relation to our proposed intervention, the nurses in the medical surgical unit will have agreed to practice nursing rounds in the unit with the aim of reducing or preventing falls among hospitalized patients.

Implementation Plan

The researchers intend to implement the proposed evidence-based project in the medical surgical units in hospital X. The intervention will be the use of routine nursing rounds in adult wards to prevent or reduce incidences of patient falls. The project is expected to commence on November 2019 and it will run for a period of eight months. The data for the intervention will be collected from each ward on the number of patient falls as well as injuries after the introduction of the intervention. Two medical surgical wards will be used where one of the wards will practice routine nursing rounds while the other utilizes call lights. The frequency of nursing rounds will be obtained throughout the implementation period. Comparative data will then be obtained to determine whether the use of nursing rounds is superior to call lights in the prevention and reduction of patent falls. The data will be collected based on a defined protocol, which is described in Appendix F. The intervention will be presented to the management of the unit and the hospital prior to its implementation. Permission will be sought from them as well as from quality care committee. This will be followed by the presentation of evidence-based information on the efficacy of the intervention in reducing incidences of patient falls. Teaching sessions with the nurses working in the unit will be organized to raise their level of awareness and understanding about the intervention. Posters will also be developed to heighten the awareness and the need for the intervention in the clinical setting. The concerns of the healthcare providers on the intervention will be addressed throughout this period.

Evaluation

The evaluation of the proposed evidence-based practice intervention will take into consideration the outcomes of routine nursing rounds in prevention and reduction of patient falls. The researchers will obtain data for the number of patient falls throughout the period of intervention. Data will be obtained from both units for comparative purposes. Data on the frequency of the nursing rounds will also be obtained. It is recommended that the nursing rounds be undertaken on hourly basis. This data will be used to determine whether there exists a correlation between the frequency of nursing rounds and incidence of patient falls. The intervention will be deemed effective if the number of patient falls is lower than that reported in the previous months before the introduction of the intervention. It will also be effective if the incidence rate of patient falls is significantly lower in the unit where nursing rounds were used when compared to the unit where call lights were used.

References

Daniels, J. F. (2016). Purposeful and timely nursing rounds: a best practice implementation project. JBI database of systematic reviews and implementation reports14(1), 248-267.

Goldsack, J., Bergey, M., Mascioli, S., & Cunningham, J. (2015). Hourly rounding and patient falls: what factors boost success?. Nursing201945(2), 25-30.

Hayakawa, T., Hashimoto, S., Kanda, H., Hirano, N., Kurihara, Y., Kawashima, T., & Fukushima, T. (2014). Risk factors of falls in inpatients and their practical use in identifying high-risk persons at admission: Fukushima Medical University Hospital cohort study. BMJ open4(8), e005385.

King, B., Pecanac, K., Krupp, A., Liebzeit, D., & Mahoney, J. (2016). Impact of fall prevention on nurses and care of fall risk patients. The Gerontologist58(2), 331-340.

Leone, R. M., & Adams, R. J. (2016). Safety standards: implementing fall prevention interventions and sustaining lower fall rates by promoting the culture of safety on an inpatient rehabilitation unit. Rehabilitation Nursing41(1), 26-32.

Meade, C. M., Bursell, A. L., & Ketelsen, L. (2006). Effects of nursing rounds: on patients’ call light use, satisfaction, and safety. AJN The American Journal of Nursing106(9), 58-70.

Mitchell, M. D., Lavenberg, J. G., Trotta, R., & Umscheid, C. A. (2014). Hourly rounding to improve nursing responsiveness: a systematic review. The Journal of nursing administration44(9), 462.

Morris, R., & O’Riordan, S. (2017). Prevention of falls in hospital. Clinical Medicine17(4), 360-362.

Najafpour, Z., Godarzi, Z., Arab, M., & Yaseri, M. (2019). Risk factors for falls in hospital in-patients: a prospective nested case control study. International journal of health policy and management8(5), 300.

Pearson, M. L. I. S., Karen, B., & Andrew, F. (2012). Evidence-based falls prevention in critical access hospitals.

Santacreu, A. M. (2015). Innovation, diffusion, and trade: Theory and measurement. Journal of Monetary Economics75, 1-20.

Severo, I. M., Kuchenbecker, R. D. S., Vieira, D. F. V. B., Lucena, A. D. F., & Almeida, M. D. A. (2018). Risk factors for fall occurrence in hospitalized adult patients: a case-control study. Revista latino-americana de enfermagem26.

Tucker, S. J., Bieber, P. L., Attlesey‐Pries, J. M., Olson, M. E., & Dierkhising, R. A. (2012). Outcomes and challenges in implementing hourly rounds to reduce falls in orthopedic units. Worldviews on EvidenceBased Nursing9(1), 18-29.

Walsh, C. M., Liang, L. J., Grogan, T., Coles, C., McNair, N., & Nuckols, T. K. (2018). Temporal trends in fall rates with the implementation of a multifaceted fall prevention program: persistence pays off. The Joint Commission Journal on Quality and Patient Safety44(2), 75-83.