Clinical governance is a process through which the health care organisations make continuous improvement strategies for improving the quality of their services and upholding high standards of care to the patients (Van Zwanenberg & Edwards, 2018). There are some key performance indicators that determine the presence of clinical governance in a health care organisation, among which fall prevention is an important one.
Falls are a public health problem word wide. Hospitalisation increases the risks of falls. Fall is clinical settings might be due to illness, medications, gait impairment and unfamiliar environment. Fall may lead to fractures, haemorrhages, prolonged hospital stay, increased mortality and moreover reducing the reputation of the clinical setting. Fall is mainly caused in the older adults and decreases their quality of living (Deandrea et al., 2013). Till now many strategies have been taken to prevent falls in the hospital inpatients upholding the clinical governance and reputation of the setting. Clinical government arrangements involve development of the evidence based fall prevention tools, policy of the trust and guidelines and extensive staff training programs. Notably, fall among the inpatients can be reduced by the seven pillars of clinical governance- Service user, carer and public involvement, Risk management, Clinical audit, Staffing and staff management, Education and training, Clinical effectiveness and Clinical information (Azami-Aghdash et al., 2013). Hence, fall prevention is highly relevant to clinical governance within a hospital setting. This paper would critically analyse the fall prevention strategies.
Three papers have been critically appraised using the CASP tool. CASP tools for qualitative research, quantitative research and systematic review has been used in analysing each of the three papers. The CASP tool helps to find and make sense of the research evidences (Nadelson & Nadelson, 2014).
Higher rate of falls are identified in the geriatrics, neurology and the rehabilitation wards. Fall among the impatient occur due to a large number of predisposing factors such as the age, mobility, impairment,certain medications, poor lighting, uneven flooring or the shortage of staff . Miake-Lye et al., (2013), have written a systematic review to assess the harms and the benefits of the multicomponent inpatient programs to prevent falls and to assess the factors associated to the successful intervention of the programs. Twenty studies have been chosen from the database. The papers chosen for the review was appropriate. Two large randomised control trails were included in the study. All the articles have been searched by the databases such as PubMed, CINAHL and the Web of science. All the studies included were in English. The rigor of the studies chosen were not analysed. The intervention components of the fall prevention program that were studied are patient education, the bed sign risk sign, staff education, alert wristband, footwear, review after the fall, toileting schedules, review of the medicines, environmental modifications, bedrail review, the movement alarm ,the hip protectors, vest belt and cuff restraints.
It has been found in the systematic review, that a regular fall risk assessment, signage of the high risk patients, patient education and manual documentation in the records of the patients have been associated with reduced fall among the hospital inpatients. In almost all the papers multicomponent in facility programs have been found to have caused a statistically significant reduction of falls among the hospital inpatients. The result of the study was also found to be consistent with the previous reviews on the inpatient fall program. The significance of the result is that the population group chosen for the systematic review matches with the actual population facing the issue; the elderly people. Most of the papers chosen in the review did not report any harm regarding the implementation of the harm reduction program. None of the papers could found any economic evaluation of the fall prevention programs. This paper included the papers that described about the role of the patient infrastructure and the patient safety and culture. One of the limitations of the research is that the systematic review is limited by the quantity and the quality of the research.
Falls by the elderly people in the nursing care facilities are common events that can cause loss of independence, injuries or deaths.
Proper exercise regimen can be helpful in increasing the muscle strength and gait among the elderly people (Granacher et al., 2013). In relation to this, Gschwind et al. (2013), have conducted a randomised control trial for assessing the effectiveness of the fall prevention program, that was developed by an interdisciplinary panel of expert, on body, power, consumption, cognition and the psychological wellbeing and the fall self –efficacy among the healthy older adults. In this trial 65- 80 years of age old people were included. The instruments that were used to assess the self-efficacy are the assessment of the static/ dynamic steady state balance, proactive balance, reactive balance, and strength and power test. Furthermore the composition of the body will be analysed by using the bioelectrical impedance analysis system. Psychosocial, cognitive and the fall risk determinants. All the participants have been randomised in to two intervention groups. The method of the randomisation was not described. The staffs and the study personnel were not blind to the study group. One of the groups completed an extensive supervised training program and the other group completed short term home based activities directed by telephonic instructions. The trials presented a safe and an active approach for the fall prevention among the older adults. The interventions used in this study were clearly defined.
The trials displayed increased psychological and physical wellbeing among the interventions groups in comparison to ones who were practicing home based activities.One of the limitation of this study is the low sample size and the fact that the control participants might not exercise as per the telephonic instructions and the absence of a control group. One of the strength of this study is that interventions compared to the early fall prevention strategy is that on the basis of the finding, exercise training programs can be taken up in the institutions. Furthermore the study also evaluates how minimum home based exercises can stimulate the physical performance adaptations.
A qualitative study by Wilson et al., (2016), was conducted to examine the perception of the nurses about the use of the evidence-based fall prevention interventions for mitigating the fall risk on the patients. The aim of the research is relevant.
As per the findings five major themes have been revealed- the before study fall prevention strategies, the use of the fall prevention interventions, the beneficial implementation strategies, the overall impact on the approach to the fall prevention and the challenges. Thirty four staff nurses were included in the study (Wilson et al., 2016). Five focus group with an average of the four to five nurses in each of the group was included. A session lasted for about 60-90 minutes. The recruitment strategy was appropriate to the aim of the research.
A semi-structured interview was conducted. The qualitative research method for this paper is appropriate and is worth continuing and provides a detailed idea about the how the data has been collected. The interview questions were well defined and relevant to the study. Ethical consideration of the study has been made as each of the participants were contacted via email and a consent form was being signed. Privacy and confidentiality was maintained during the data storage. Proper data collection instruments have been used in the study such as two-digital audio recorders.
The collected data were analysed by a constant comparative study. A thematic analysis has been used. Major and the minor themes were being identified by two independent researchers. The rigor of the studies has been maintained by the cross checking of the transcripts.
As per the findings , most of the nurses have reported that before the study most of the importance was given only on the generalised fall prevention strategies, but evidence based practice goes beyond the generalised fall prevention interventions. However, the study had rightfully identified some of the limitations. The nurse did not discuss about mental status, increased risk of injury, hence fall prevention perceptions of the nurses in the other categories were not known. Furthermore, the sample size was also small to be appropriate for the generalised population. However, the strengths of the study is that this study increased the mindfulness of the fall and collaboration between the interdisciplinary team members.
Hence in conclusion it can be said that fall prevention among the hospital inpatients can be prevented by prevention programs such as the proper physical activities to improve the gait among the fall prone people, vitamin D supplementation for increasing the muscle strength has been found to be useful. Furthermore, other options such as environmental assistive technology, staff training and medication review has been found to be useful in preventing falls. Although there are several limitation of the three papers, but the papers definitely provide useful evidence about the various fall prevention strategies.
References
Azami-Aghdash, S., Tabrizi, J. S., Sadeghi-Bazargani, H., Hajebrahimi, S., & Naghavi-Behzad, M. (2015). Developing performance indicators for clinical governance in dimensions of risk management and clinical effectiveness. International Journal for Quality in Health Care, 27(2), 110-116.
Granacher, U., Gollhofer, A., Hortobágyi, T., Kressig, R. W., & Muehlbauer, T. (2013). The importance of trunk muscle strength for balance, functional performance, and fall prevention in seniors: a systematic review. Sports medicine, 43(7), 627-641.
Gschwind, Y. J., Kressig, R. W., Lacroix, A., Muehlbauer, T., Pfenninger, B., & Granacher, U. (2013). A best practice fall prevention exercise program to improve balance, strength/power, and psychosocial health in older adults: study protocol for a randomized controlled trial. BMC geriatrics, 13(1), 105
Miake-Lye, I. M., Hempel, S., Ganz, D. A., & Shekelle, P. G. (2013). Inpatient fall prevention programs as a patient safety strategy: a systematic review. Annals of internal medicine, 158(5_Part_2), 390-396.
Nadelson, S., & Nadelson, L. S. (2014). Evidence?based practice article reviews using CASP tools: a method for teaching EBP. Worldviews on Evidence?Based Nursing, 11(5), 344-346.
Wilson, D. S., Montie, M., Conlon, P., Reynolds, M., Ripley, R., & Titler, M. G. (2016). Nurses’ perceptions of implementing fall prevention interventions to mitigate patient-specific fall risk factors. Western journal of nursing research, 38(8), 1012-1034
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