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The aim of the project is to answer the following question: What is the effectiveness of increased patient education and participation with regular exercise-physical therapy versus current hospital fall prevention programs with limited exercise-physical therapy, in promoting balance and stability thus minimizing falls and fall-related injuries, in senior patients within a period of three months? . The change plan consists of five major steps: the design of the program based on patient education and physical therapy, the measurement of baseline falls and fall-related injuries in a facility, the intervention based on two prevention strategies (education about risks related to falls and exercises), evaluation of the plan (the comparison between the fall rates in the control group and the established baseline), and methods necessary for sustainment. The patients will be divided into two random groups, intervention and control, to ensure that the results are valid and generalizable. All internal stakeholders (patients, nurses, providers) will be involved in project implementation, which is based on Lewins theory of planned change.
Introduction and Proposal
Falls in senior patients are a frequent occurrence and can cause fall-related traumas and psychological distress. Repeated falls, when a patient falls two or more times, can result in the emergence of anxiety disorders and other conditions; as well as, client dissatisfaction, increased expenses, and higher mortality rates. The purpose of the paper is to consider interventions aimed at minimizing patient falls.
Descriptive Statement
One in four senior patients will experience a fall resulting in physical and-or psychological trauma. Consequently, health care institutions experience greater expenditures, and nurses are overloaded with excessive duties (Ungar et al., 2013). At present, hospitals have specific fall prevention programs which require increased nursing care, hourly rounding, and other approaches. Nevertheless, evidence suggests that they are ineffective and other interventions should be considered. According to the latest research, the issue of falls in senior patients can be addressed through refined patient education and their participation in regular exercise. Evidence suggests that physical therapy has a potential to improve a patients balance and stability through enhanced muscle tone, which leads to minimizing falls (Noll, 2013). Proceeding forward, the timeframe for testing this intervention is three months since it is an adequate amount of time to achieve the necessary outcome and analyze its efficiency.
Rationale
The proposed plan is viable for the clinical issue since it will aim at a significant reduction in the problem using the available resources. The intervention will implement elements from such educational programs as: A Matter of Balance, Stepping On, or Otago Exercise Program. Evidence suggests that they prevent falls in more than 30% of senior patients (Carande-Kulis, Stevens, Florence, Beattie, & Arias, 2015). The plan will also require educating nurses regarding the appropriate exercises so that they can instruct their patients and patient families correctly. Nurses, being bed-side leaders, will demonstrate and observe if senior patients exercise properly and regularly. Several educational sessions should be adequate to provide nurses with the necessary knowledge and skills. Since the nursing staff is typically aware of the individual needs of each patient, they can also adjust the program accordingly.
Resources
The major resources required include expenditures to educate staff on the chosen intervention program. In addition, nurses will have to allocate their time to learn the essential techniques and instructional methods. To implement these educational sessions, the hospital will have to allocate money and time to educate nurses (Kenny, Romero-Ortuno, & Kumar, 2016). The minor expenses include handout materials to support patients understanding and audio-visual aids (DVDs, pamphlets, mobile-applications). These tools will help ensure that patients do not need to put much effort into memorization. Nurses will observe patients to prevent traumatization and instruct their families so that they can support patients when they are exercising on their own.
Stakeholders
The primary stakeholders include senior patients (who are 65 and older) because they will experience the immediate effects of the intervention (Bourne, 2016). Nursing personnel belong to this group as well since they will play the main role in providing education to patients. The secondary stakeholders are patients families and other caregivers since they will be partly engaged in ensuring the intervention is implemented fully. Hospital administration can also be included in this category since they will evaluate the outcome of the program.
Projected Benefit
The benefits of the proposed plan will be reflected in increased patient safety through improved muscle tone, which will ensure that senior patients can control their gait and balance (Noll, 2013). The possibility of fall-related injuries will be minimized and result in decreased mortality. The financial benefits will be reflected in reduced expenses, which, as a rule, are made to remedy the consequences of falls. The return on investment (on the example of the Otago Exercise Program) is approximately 36%. The cost per participant is $1.34, and the cost per hour for the entire unit is $53.86. The expected benefit based on the research by Carande-Kulis et al. (2015) is $461. Therefore, the advantages of program implementation clearly outweigh the expenditures.
Due to the expected increase in our senior population, immediate interventions are required to address the issue of falls in these individuals. Traumatization of hospitalized senior patients is a frequent occurrence, which results in client dissatisfaction and increased costs for institutions. The proposed plan has the potential to resolve this urgent issue while bringing multiple benefits for hospitals, nurses, and senior patients.
Literature Review
A literature review aids in comprehending acquired research. In addition, it provides an opportunity to evaluate the existing body of knowledge and determine gaps that exist within it. The purpose of this paper is to review the articles related to the approved change topic.
Synthesis
According to Stenhagen, Ekstrom, Nordell, and Elmstahl (2014), senior individuals can experience various health-related issues if they fall frequently. The team has researched 2,931 patients using Short Form Health Survey, and they found that most individuals experiencing repeated falls were dissatisfied with their quality of life. These results express the need for immediate interventions as proposed by the PICOT question. According to Moraes Oliveira et al. (2016), one of the tools utilized to predict falls in senior patients is the AIFE instrument. Nevertheless, this tool was proven to be inefficient; therefore, the team refined it to include the aspects of vulnerability. In their turn, Aizen and Zlotver (2013) investigated the feasibility of developing risk-prediction tools to prevent falls. In their cohort study, they researched 1,013 senior patients and analyzed the results using logistic regression models. They determined that predictive tools do not lead to a reduction in falls. Thus, these findings also support the PICOT question and evidence the need for practical interventions such as patient training.
Researchers assume that senior adults can benefit greatly from regular exercise since it improves their balance, muscle tone, and gait, thus decreasing the possibility of falling. The Otago exercise program is considered an effective intervention to improve balance in older adults. Patel and Pachpute (2015) have proved that this program positively affects the senior population; the strength and balance training that they received has decreased the number of falls in 24 out of 30 individuals. Yoo, Chung, and Lee (2013) have observed similar results. They researched 21 elderly women and found that augmented reality-based Otago exercise drastically improved their balance and gait. In addition, Imaoka, Higuchi, Todo, Kitagwa, and Ueda (2016) have proved that senior patients receiving low-frequency exercises, accompanied by vitamin therapy, exhibited reduced fall rates.
Tai Chi training is also considered effective in reducing falls in the elderly. According to Zhao and Wang (2016) who have analyzed the results of 2,796 individuals, Tai Chi training significantly improves balance in elderly individuals. These findings correlate directly with the items of the PICOT question and require research on hospitalized patients. Moreover, Haines et al. (2013) found that patient education has a potential to reduce hospital expenses by 4%. Therefore, future research will apply the discussed findings to senior hospitalized patients to determine whether patient education and physical therapy will result in fall reduction.
Comparison
The articles by Patel and Pachpute (2015), Zhao and Wang (2016), and Yoo et al. (2013) provide evidence proving that regular exercise performed by senior adults positively affect their balance and stability. Thus, minimizing the possibility of falls. Nevertheless, the main limitation of these studies can be concluded to the fact that they do not center on hospitalized patients.
The research by Imaoka et al. (2016) studies institutionalized patients, but it does not provide guidelines in terms of concrete therapeutic strategies. The outcomes of the study by Stenhagen et al. (2014) also do not provide evidence regarding hospitalized patients. One of the controversies noticed in the articles is linked to the evaluation of vulnerability to falls. According to Aizen and Zlotver (2013), prediction tools have a low value in preventing falls while Moraes Oliveira et al. (2016) consider that certain instruments can be refined. Nevertheless, the article by Haines et al. (2013) supports the assumption that patient education is a feasible measure; therefore, institutions should resort to it to address the issue of falls and minimize their costs.
Analysis
Increased patient education and participation in regular exercise has a potential to decrease the incidence of falls in senior adults, which has been evidenced by the literature review. Nonetheless, the limitations suggest that further research is needed to understand whether similar results can be achieved if the proposed interventions are applied to hospitalized patients. Therefore, the proposed change project can contribute greatly to the existing body of knowledge and will provide new insights into possibilities of fall reduction in senior hospitalized patients.
Nursing Theory
Nursing theories strongly support medical specialists in their practice. Similarly, the application of nursing theory is essential during the research process to create a more credible and reliable study. The purpose of this paper is to discuss the nursing theory relevant to the approved clinical issue, which is the prevention of falls in senior patients.
Chosen Theory
The Health Belief Model is one of the oldest and most fundamental theories. The concept describes motivation as the main factor in an individuals decision-making related to his or her health. The theory pays particular attention to the state of a persons psychological preparedness for certain actions, as well as to his or her belief that certain behavior can reduce the likelihood of risks to their health (Barkway, 2013). The Health Belief Model has been developed within the framework of traditional social psychology, and the main proposition underlying it is that the perception of a personal threat is the main prerequisite for changing a persons behavior. Consequently, patients should understand that certain actions (or absence of actions) could have consequences in the form of preservation or disruption of health (Barkway, 2013). The main components of this theory are individual differences among people, awareness of threats to health, expectations about the implementation of actions, and factors of employing a certain behavior.
Evidence-Based Research
In the past, the Health Belief Model was used rather infrequently. In particular, it was utilized to determine the aspects contributing to or impeding decision-making on the use of preventive medical care. Therefore, this concept was considered in describing the factors for seeking help when patients had no symptoms of a disease (Jones, Smith, & Llewellyn, 2014). Notably, the model was used to investigate preventive behavior in the field of sexual behavior and transmission of HIV/AIDS, and gradually expanded to include other aspects. At present, it concentrates on studying motivation as a trigger of certain conduct.
In current research, this model is employed in the study of preventive care and health promotion (Orji, Vassileva, & Mandryk, 2012). In nursing practice, the model has been used to implement successful change in such areas as diet and weight management, prevention of sexually transmitted diseases, health promotion, and many others. Therefore, this model is highly applicable to current nursing practice since its scope allows for researching various behaviors and health-related decisions of patients.
Predictions
The Health Belief Model makes positive predictions regarding the potential for increased physical activity and education provided to senior patients in preventing falls. Based on the latest evidence, individuals beliefs about personal risks and expected consequences build the mechanism for changing their behavior and determining their willingness to act (Bishop, Baker, Boyle, & MacKinnon, 2015). Thus, to prevent falls in elderly patients due to increased physical activity, it is necessary to change their health belief system. This will help them realize their vulnerability and understand the need to strengthen their muscles, balance, and gait, to avoid falls and other negative consequences. Nurse inclusion and instruction are necessary to ensure the system of beliefs of patients can be changed. After patients have been made aware of the necessity to exercise, their desire to engage in physical therapy will become an internal motivation.
Rationale and Support
The Health Belief Model is highly applicable to fall prevention. Since nursing interventions such as hourly rounding, specialist collaboration, and other measures aimed at securing patients proved to be ineffective, the need to shift the emphasis to patients has become evident. Falls in elderly individuals are the result of poor balance and weak muscle tone; therefore, patients should be stimulated to engage in physical therapy. This problem will be successfully alleviated when patients comprehend the need to participate in regular exercise, which can be achieved through changing their health belief system (Tkatch, Musich, MacLeod, Alsgaard, Hawkins, & Yeh, 2016). Therefore, the application of the model to a study on the effects of increased patient education, combined with physical therapy to reduce falls in senior patients, will help to validate this assumption.
Change Theory and Nursing
Change is inevitable in every aspect of life and crucial for development. Changes frequently become a problem due to the resistance of stakeholders and other obstacles. Change theories are supposed to empower the process of change and make it less painful for all parties involved. Thus, this paper will provide an analysis of Lewins Three-Step Change Theory in the context of nursing, review stakeholders and their considerations concerning the change project, predict possible obstacles, and provide strategies for their success. The applied theory will manage a project dedicated to the comparison of the effectiveness of increased patient education and participation with regular exercise/physical therapy to current hospital fall prevention programs with limited exercise/physical therapy.
Change Theory and its Implementation
Change theories can be applied to various organizations or projects, including nursing. The American Organization of Nurse Executives singles out five nurse executive competencies such as communication, knowledge, leadership, professionalism, and business skills (Shirley, 2013, p. 69). Demand within the category of leadership is a demonstration of change management skilfulness by nurse executives. It is important to choose an appropriate change theory to facilitate the stages of project implementation, management, and evaluation.
One of the theories that is frequently used in nursing is the one developed by Kurt Lewin, the pioneer of change theories (Shirley, 2013). Lewin was the first to identify three stages which must be passed to implement a change (Mitchel, 2013). He identified unfreezing, moving, and refreezing as the significant phases of change. Unfreezing presupposes preparation for change. During this stage, a change agent or nurse leader is supposed to realize the existing problem, establish the change process, and inform stakeholders about the need for change. The moving or transitioning stage requires treating change as a process. This stage necessitates creating a detailed plan of action and engaging people to try out the proposed change (Shirley, 2013, p. 70). During this stage, it is important to reveal and overcome fears. It is also essential to manage communication between the involved parties since misunderstandings can become an obstacle in reaching the final goal. Finally, refreezing comprises stabilizing the change so that it becomes embedded into existing systems such as culture, policies, and practices (Shirley, 2013, p. 70). The third stage is crucial for institutionalizing change, as it contributes to change sustainability in the future.
In the case of managing change in patient education, it is possible to apply Lewins theory. For this project, the unfreezing stage includes the analysis of the current situation. The existing hospital fall prevention program with limited exercise/physical therapy is not efficient. Awareness of the problem leads to a demand for change. Thus, it is supposed that interventions with patient education and regular exercises can be effective for senior hospitalized patients. The second stage of the theory will contribute to the development of a detailed plan of patient education interventions. Moreover, this stage defines the responsible parties and outlines the expected outcomes. Also, it is important to assess possible risks of the planned interventions. Finally, the third stage of the theory is used to manage the assessment of the planned interventions. If efficient, it will be possible to use them on a regular basis. Overall, Lewins Three-Step Change Theory is useful for managing change processes in nursing since it assists in covering the essential stages for a successful and efficient change project.
Stakeholders Involved with Change and Other Considerations
Since the change project will be implemented in a hospital, it involves different groups of stakeholders. Major stakeholders are patients, nurses, and administration of the healthcare facility; relatives of patients are minor stakeholders. A primary concern of all stakeholders is patient safety. For elderly patients, safety is important because falls in hospitals can negatively influence their health and recovery process. However, they can be suspicious of a new project since senior patients do not accept changes eagerly. Nurses will be managing the project implementation. Thus, they should be positive about the project and consider it an opportunity to improve patient outcomes. Hospital administration is a controlling party in the change process. They will benefit from the successful project implementation, but also should control its adherence to nursing standards. Patients relatives, although being minor stakeholders, are concerned about the health and safety of their family members and can oppose changes in case they consider the project dangerous or ineffective. It is important to learn the considerations of all stakeholders since they may create obstacles in the implementation of the change project.
Strategies to Overcome Stakeholder Resistance
Resistance to change is a common aspect of any change process. Resistance to change in this project can be managed with the help of Lewins theory. During its unfreezing stage, the project manager should predict the possible reasons for resistance to address them during the moving stage. Thus, an informative strategy can be applied. Stakeholders should be informed about the details of the change project concerning increased patient education and participation with regular exercise/physical therapy. Another applicable strategy for this project is that of a positive example. The presentation of successful implementation of similar projects in other healthcare facilities are likely to reduce the resistance stakeholders.
Potential Obstacles and Strategies for Overcoming Them
The implementation process of a change project is frequently interrupted with obstacles, which can be of structural, financial, or organizational character (Grol, Wensing, Eccles, & Davis, 2013). For this change project in patient education, the potential obstacles can include a lack of finance and organizational problems; the financial component is critical for this project. Lack of finance can interfere with successful project implementation. Thus, authors of the project should find adequate sponsors to avoid this obstacle. As for organizational issues, they can comprise such obstacles as patients or staff resistance to change. Also, over regulatory leadership can create a barrier for change (Gbadamosi, 2015). The strategy to overcome these obstacles is emotional intelligence (Foltin & Keller, 2012). Emotional intelligence has a positive impact on motivation, communication, and teamwork, which are significant for the implementation of the change project. In terms of Lewins theory, this strategy can be used during the moving stage. Another possible strategy applied during this stage is the presentation of project benefits. It will provide a picture of the potential positive results and influence the need for changes in patient education.
Furthermore, technology development and contemporary research provide opportunities for improvements in patient care, and suggest more efficient approaches than existing ones. The role of a nurse in such conditions is to be attentive to areas requiring change, discuss these problems, develop change projects, and implement them. However, apart from the creation of change projects, it is crucial to predict possible problems and provide strategies in managing them. Moreover, defining all stakeholders is necessary because it helps in distributing roles during the implementation process.
Implementation Plan
The first step in the change project is designing a program of patient education and exercise/physical therapy. The strategy to be applied to this step is based on evidence-based practice, i.e. the program should comply with the available information on fall prevention programs and their implementation in various facilities (Spoelstra, Given, & Given, 2012). The next step is measuring baseline falls and fall-related injury rates within a given facility. The strategy applied to this step is the framework of research in health care; the researcher must be unbiased and committed to fully and accurately documenting the existing situation.
The third step is conducting the intervention. This step should comply with two major fall prevention strategies: education about fall-related risk factors and exercise programs (DiBardino, Cohen, & Didwania, 2012). Also, it should be ensured that the intervention is conducted correctly so the results are reliable, valid, and generalizable; for this, patients should be divided into two random groups (intervention and control).
The final step is evaluation; after three months, the researcher will be able to compare the results of the intervention to the fall rate in the control group versus the baseline rate. The key stakeholders in the presented project are patients (the control group included), health care providers who will implement the project (including the researcher), and the facility administrators who will provide necessary resources for the implementation stage, e.g. premises and equipment for patient education sessions and exercise/physical therapy.
Communication Strategies
In developing communication strategies, it is important to recognize the stakeholders and to plan how communications among them should be carried out. First, the researcher should contact the facility administration and health care providers to explain the necessity of the proposed intervention. The strategy to be employed in this communication is facility-centeredness; the researcher should not explain the general importance of fall prevention programs but instead refer to fall rates in the given facility. Further, evidence should be presented that fall prevention interventions like the proposed one have been successful in other facilities, which is confirmed by scholarly studies (DiBardino et al., 2012). A plan should be demonstrated so that the facilitys decision makers can see that the researcher has developed every step of the intervention and strengthened the research design with relevant academic literature.
In communicating with the health care providers who will participate in the implementation of the project, the researcher should regard them as fellow researchers. According to Smith (2013), nursing care providers may adopt many roles in their practice, e.g. act as administrators and facilitators, and in the proposed project, they should be encouraged to act as researchers instead of mere performers of project implementation instructions. This is expected to increase their involvement and improve the quality of intervention provided.
Finally, communications with patients should be carried out according to the strategy of overcoming barriers to patients willingness to actively engage in their care (Berger, Flickinger, Pfoh, Martinez, & Dy, 2013, p. 548). The purpose of the intervention, procedures and activities, and the expected outcomes should be clearly explained to the participating patients. It should be recognized that the intervention may be difficult for some patients. Therefore, the researcher and health care providers must communicate with the participants in a comforting and encouraging manner.
Educational Requirements
Mitchell (2013) claims that staff education and training [is] a pivotal part of the change process (p. 37); in fact, one of the theories of change in nursing practice is the normative re-educative theory that implies the change of behaviors through the provision of certain information. In the proposed change project, training and education will play a significant role. First, the health care providers who will be involved in the intervention need to be trained according to the pre-designed program of patient education and participation and exercise/physical therapy. In this regard, the requirement is that the researchers who will act as educators are not only provided with educational materials, but also equipped with relevant knowledge on how patient education and exercise/physical therapy can be delivered effectively. This training will be provided by the researcher as the author of the intervention program and project plan. Evaluation will be conducted upon the completion of training and before the beginning of the intervention (part of the implementation stage); health care providers will need to demonstrate their ability to hold educational sessions with patients and to understand the rationale behind the intervention.
Concerning the exercise/physical therapy part of the intervention, the researchers experience may be insufficient in terms of training health care professionals. Hence, an external expert can be invited to teach providers how to conduct appropriate physical activity sessions. The consulting expert should be proficient in fall prevention exercise programs. A requirement to this aspect of training is that differences among patients are explained, i.e. what physical activities are recommended more for certain groups of patients and not others. During the evaluation, health care providers will be expected to demonstrate their ability to carry out exercise/physical therapy sessions and differentiate among patient needs for particular types of exercise.
Safety, Ethics, Scope of Practice, and Regulations
Several areas of facility operation and health care providers work need to be considered to ensure the plan will remain in compliance. First, patients safety needs to be guaranteed; for this, researchers must create learning and physical activity environments in which senior patients health risks (primarily associated with frailty-related injuries) are reduced. Second, ethical principles should be followed; for example, Mubashir, Shao, and Seed (2013) stress that the principle of autonomy, i.e. the recognized patients ability to make independent decisions, should be considered in the implementation of fall prevention programs. Patients should be well-informed and participation voluntary. In case a patient wants to stop receiving the intervention, he or she should be excluded from the group. Also, the program should be designed according to the principles of beneficence and nonmaleficence, i.e. it should be ensured that the patients health or treatment plans are not undermined by the intervention.
Third, the intervention should be aligned within the scope of practice of those health care providers who will implement the project plan. It should be ensured that educational material provided to patients does not contain information that nurses may not be authorized to provide; an example being medications and/or treatment plans. Also, it should be stressed that patient education sessions and exercise/physical activity sessions are not designed by the providers. Instead, they should be based on academic literature and evidence-based practice, ensuring the intervention is not beyond the scope of practice. Finally, it should be guaranteed that the intervention program complies with any external and internal facility regulations. For this, the researcher should consult the facilitys administration and legal team and, if needed, adjust the project plan to any requirements.
Support from Literature Review
As it has been demonstrated, the change project implementation plan relies on relevant academic literature; moreover, the planned activities are aligned with the literature review conducted previously and nursing theories identified as related to the PICOT question. Initially, it was confirmed by Stenhagen, Ekstrom, Nordell, and Elmstahl (2014) that frequent falls among senior patients can cause a variety of negative health effects, which justifies the need for the presented project. Further, a study by Aizen and Zlotver (2013) shows that risk-prediction tools are not effective in reducing the fall rate, which is why practical interventions are required. Concerning regular exercise/physical therapy, several confirmations of its effectiveness had been found in the relevant literature, including articles by Patel and Pachpute (2015) and by Yoo, Chung, and Lee (2013). In addition, Haines et al. (2013) corroborate that patient education can be effective in fall prevention programs.
Evaluation and Dissemination of Outcomes
Assessment and dissemination of research results are significant steps of any study. They allow for measuring the success of a proposed intervention, and evaluating the benefits that the research can bring to the existing body of knowledge. In addition, they ensure that the scientific community and other healthcare institutions can employ similar practic
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