The Disorders of Mobility and Balance in the Hospital Environment - Essay Example

 The elderly have a variety of problems associated with old age. Poor physical health, dementia, sleep problems, mental issues, loss of memory, hearing problems, visual impairment, teeth loss and peri-odontal problems constituted some issues Climbing stairs became difficult. Adjustment problems and psychosocial problems with others interfered with their social relationships. Difficulty to walk and carry on their daily activities made them dependent on others. Dementia was a serious problem which was upsetting and had the families taking on the responsibility of seeing the patient through to the terminal days. Those who previously were able and moving about independently found themselves partially or totally dependent on others. With the difficulty in mobility, they tended to run into accidents most of the time. Having falls was a frequent event that made the elderly helpless and dependent. Dementia, cognitive deficits, unfamiliar surroundings, altered ability to move around, environmental changes, diminishing eyesight, lack of confidence and unnoticed dangers were known to contribute to falls (Clemson et al, 2003). The prevention of falls was a plan aiming at improving the quality of life of an aged person by not allowing it to happen. It could be imparted by a multidisciplinary team through multifactorial programs of screening and interventions (Vind et al, 2007). Reflection was the process adapted by nurses to increase their learning experience. “Reflection in the context of learning is the generic term for those intellectual and affective activities in which individuals engage to explore their experiences in order to lead to new understandings and appreciations” (Boud et al, 1985 in Brooker and Nicol, 2003). Nurses gain experience from just being involved in nursing activities in the ward. However their wealth of experience was obtained only from reflection of their activities. Reflection allowed them to look back and recall the significant points about their activities, who guided them and what was the new information collected (Brooker and Nicol, 2003). Models of reflection had been suggested by Gibbs (1988), Johns (1996) and Boud et al (1985) (Brooker and Nicol, 2003). Reflective research was the means of learning from experience. Nurses had become busy practitioners considering the complexity of the environment they work in. The difficult and varying interpersonal relationships in the hospital milieu warranted that the nurse was to possess characteristics which helped her survive (Taylor, 2001). Whatever the constraints, the nurse had to deliver. Action research and reflection were two components which involved almost all the work that was done by a nurse. The educative nature of action research contributed to the learning experience. The relationship with patients could grow through psychosocial aspects of behavior. Problem-focused research was possible with this kind of research. The specific context also was significant for reflection and remembering for future recall (Taylor, 2001). Trying out a specific intervention which was going to benefit patients in the future was possible. Improvement in therapy and involvement to change it could add to the learning process through reflection. The change process could involve participants and nurses in a research relationship. Action research had contributed to many of the changes in the nurse’s life. Self-directed learning process was conducive to more effectiveness in their practice and the clarification of their roles (Taylor, 2001). Even participants could be empowered through the efforts of the nurse. The diverse aspects of solving problems, planning for changes and frequent evaluation were dealt with in reflective research. The self-esteem as practitioners and gaining knowledge everyday of their lives provided personal and professional worth. Successful practices resulted from ardent endeavours on the part of the nurse and a large amount of personal involvement (Taylor et al, 2001). Merely following routines could dampen the efforts at improving one-self. Selecting a model simple enough to be used on a daily basis, nurses were able to reflect frequently on their experiences. Negative emotions could be detected and handled in a positive manner to overcome the issue. Both negative and positive experiences provided learning outcomes (Brooker and Nicol, 2003). Deep reflection beyond superficial thoughts yielded results of valuable experience. Mentors could also help to guide through meaningful reflective sessions. Reflections were needed for the closing the gap between research and practice (Nichol and Higgins, 2004). Expressing and widening the knowledge base was a daily phenomenon and part of the life as a nurse. The concept of reflection had influenced practice and research over the years. Nursing education programmes had been focussing on reflection as a means of building one’s practice and attaining competency. The ability to reflect helped to build the capacity to knowledge creation. Values or perceptions could be changed through the vehicle of reflection. New perspectives could be constructed (Nichols and Higgins, 2004). Collaborative enquiry helped reflective capacity among health staff (Lehmann, 2004). The wide disparity between researchers and other groups which included the health professionals and policy makers could be narrowed through reflective practice. Reflective research provided ownership to knowledge. The empowerment of the nurses was through reflective research and practice. The low morale of nurses could hinder the best evidence practiced. Reflective research helped to boost their confidence (Lehmann, 2004). Commitment too increased. Writing a reflective journal could help learning by reflection (Brooker and Nicol, 2003). Jotting down notes immediately after the experience could hold as much details as was possible for frequent recall. Delay in making the entries resulted in the loss of some vital Figure 1 Gibbs Model of reflection memories and the value of the reflection became less. Development as a professional depended on the speedy recording of reflective experiences. Merely completing work and reaching competency by the Nursing Code was insufficient for being a good knowledgeable professional (Brooker and Nicol, 2003). The quality of a nurse was judged by her incomparable valuable experience gained through reflective processes rather than by the number of years she had completed. Having decided to follow Gibb’s model of reflection and do the journaling too to obtain the recent advances in the prevention of falls in various environments, I applied Gibb’s model to the event in my ward (Brooker and Nicol, 2003).. Description of the event Mrs. Smith was a patient recovering in the rehabilitation ward from arthritis. She was on anti-psychotic drugs for schizophrenia. Her joints were still not moving to their full extent. She had been there for a few days and was having physiotherapy in addition. Her condition was showing improvement and she was happy that she had not become bed-ridden. We had spent a jolly few minutes just ten minutes back. When I heard a big thud followed by screaming, I rushed to the ward to find Mrs. Smith on the floor groaning in pain, I contacted the orthopaedician to see her. She had developed a fracture of the hip bone and needed to remain in hospital for more days. She had in her hurry got up following a sudden abdominal pain which gave her the urge to visit the toilet. Slipping on her shoes, she fell down causing the fracture. Research Question How could I as a nurse prevent my patients from falling? Feelings about the event I was feeling upset that I could not prevent her fall. Could I have done anything to prevent that fall which made her miserable and reduced the quality of her life? That set me thinking. Was I not responsible for Mrs Smith’s accident while she was in the ward? Could I have ensured that her shoes were to be nonskid? Should I not have removed the shoes out of the way so that she had to stand up first and then worn her shoes. How could I have known that she wanted to get up? I should have made her promise that she would call me when she wanted to get up or was that enough? The incident really troubled me. Could she have fallen due to imbalance or dizziness? Was she having a fall in blood pressure when she got up from the lying position? Did any of her drugs cause any problem? Why did she have abdominal pain? Was it her food? Evaluation about the event The fact that I was near at hand made me feel a little relieved but the damage had been done: she had sustained a fracture. I do not know what was good about the experience. Everything else was bad especially for the patient. Maybe it was good in that I realized that I needed to do something for preventing falls at least in my ward. Analysis about the event The event was a frequent occurrence in the hospital. The hospital records informed me that on an average, there was a fall once in four days which brought number of falls to 8 in a month. This was not a small number. Something had to be done. Planning to search for literature in the library, I set out on learning how to prevent falls. The librarian provided me all the information on getting started. My intention was to specifically search for evidence-based ways of preventing falls because nursing practice expected us to. Conclusion To understand what else I could have done, I started my search of the literature. Planning to make suitable jottings in my journal as I learnt new ways to prevent falls and also add where I got the information from, I decided to go about things in a systematic way. My intention was to be able to convince my colleagues and supervisors and the administration about the necessity to make the alterations possible in our wards and how the prevention could lead to less distress and the economical savings. The search for articles on elderly falls. The Ebscohost site provided plenty of material for nursing especially the Cinahl Plus journal. The Internurse was also searched through. Using the words falls, elderly falls, falls prevention, falls in acute care and community falls, I looked through nearly 34 articles and selected 2 for this assignment for critical analysis. I also selected 5 for just the information on the prevention of falls. Using advanced search and Boolean tools, all the articles that I found were peer–reviewed and scholarly journals from the years 2007 to 2011. Beasley indicated that falls were a serious problem in aged care facilities (2009). They were also a problem in the community (Martin et al, 2008), in rehabilitation centres (Dreher et al, 2008) and in nursing homes (Rapp et al, 2008). Preventive measures were possible in the instance of eldelry falls. Prevention of falls had been studied by several authors (Rapp et al, 2008, Beasley , 2009; McCarter-Bayer et al, 2005) Risk factors had been studied by some researchers (Fonad et al, 2008). Hill et al discussed the increased utilization of resources for falls in a hospital setting (2007). I selected the first article because the authors were people who were qualified for providing the information and also convinced me that studies were hard to be replicated in different settings. The second one could provide information about measures to be taken in one’s home. This was so that I could be able to educate my clients and families when they go home. Both the articles could also guide me on the manner of research for preventing falls. The two articles for critical analysis were the reports of Hendriks (2008) and Iinattiniemi (2009). Analysis of research articles Hendriks, M.R.C., Bleijlevens, M.H.C., van Haastregt, J.C.M. , Crebolder, H.F.J.M., Diedricks, J.P.M., Evers, S.M.A.A. et al. (2008). Lack of Effectiveness of a Multidisciplinary Fall-Prevention Program in Elderly People at Risk: A Randomized, Controlled Trial. J Am Geriatr Soc 56:1390–1397, 2008. Blackwell Publishing. This article was written by a qualified group of researchers who belonged to the various health organisations and departments in the University of Maastricht in the Netherlands. It was well-written, precise and without jargons. The qualification and departments the researchers worked for indicated their prowess in health care knowledge. The title was clear, accurate and unambiguous (Coughlan et al, 2007). The study was a randomized controlled trial. The objectives, design, settings, participants, intervention, measurements, results and conclusion were clearly identified in the abstract which provided an impetus to read the whole article. Logical consistency was maintained throughout. A natural flow helped reading it. The research problem was obvious but it had not been placed under a heading: it was falls in elderly people. There was no literature review. A version of the intervention adopted in London was being adjusted to the Dutch surroundings and the objective was to assess the effectiveness of the multidisciplinary prevention program for falls over the usual care. No specific theoretical framework was described. The outcomes measures were falls and daily functioning. Three hundred and thirty-three Dutch people over the age of 65 years who had recently visited the emergency department for a fall were the participants. Exclusion criteria was the difficulty to speak Dutch and cognitive impairment detected by a score of less than 4 on the Abbreviated Mental Test. Two groups were formed: one group had the adapted intervention from London and the other was the control group which had the usual care for prevention. Issues of ethical considerations were almost nil. The Medical Ethics committee approved the design of the study. The concepts and terms were well defined. The confidentiality of the participants was managed well and the participants were protected from harm. Methodology was well identified. SPSS version 1.3 was used for data analysis. Rigour was maintained in the study. The findings did not reflect the benefits of the study in London. The multidisciplinary falls prevention was not of any particular significance for the treatment group and no difference was recorded for the two groups. The adaptation of the study to the Dutch environment could have influenced the benefits. Also there was an individual bias on the part of some practitioners who had patients in the study. The long duration of months could have decreased the effectiveness. Differences in the population could have affected the results. Deviations from protocol were another cause for the ineffectiveness. Lack of adherence to the program also had an influence. Recommendations had been made for future research. It was found that the multidisciplinary falls prevention programme was not suitable for the Dutch environment. Better interventions could have worked. The effectiveness of the programme was to be ensured by some means. Efforts were to be taken to enhance adherence to the recommendations for fall prevention. That effectiveness of a programme in one setting did not ensure its effectiveness in another setting was the main point I learned from this study. The experimental and implemented versions also could be different. References were adequate. Iinattiniemi, S., Jokelainen, J. and Luukinen, H. (2009). Falls risk among a very old home-dwelling population. Scandinavian Journal of Primary Health Care, 2009; 27: 25-30 Taylor and Francis group. The objective of the study was the exploration of obvious risk factors for falling in the elderly. This was a prospective study of the home-dwelling population. Postal questionnaires and clinical tests were useful for collecting baseline data in this study. The incidence of falls was obtained from telephonic interviews every month. There was a natural flow to the report. The results and data collection were good. Five hundred falls occurred at the rate of 2 falls per person. History of frequent falling, visual problems, antipsychotic drugs and apprehensive feelings were all risk factors. The steps of the report were logistically written. Literature review was fairly short. Gait and problems of imbalance were risks that led to falls. Other risks were female gender, older age group, history of fall, lower extremity strength, impaired vision, cognitive impairment. More risks were mentioned in the report. The sample was 273 subjects above the age of 85 years. The prospective research could evaluate fall prevention in the elderly and come up with risk factors. The tools used were the questionnaires. The conclusion was appropriate and answered the objective mentioned earlier. Depressed patients were assessed using the Geriatric Depression Scale. Cognition was measured using the Mini Mental State Examination. Falls were found associated with worsening mental agility, little physical activity, feelings of apprehension like anxiety and fear, urinary problems, in the past two weeks, depressed state of mind, visual problems during movement and use of anti-psychotic drugs. Future falls could be predicted in the multivariate analysis. The predictors were fall history, bad vision, and use of anti-psychotics similar to falls in the younger age group. The anti-psychotic drugs could produce extra-pyramidal symptoms or anti-cholinergic effects which could be a risk for future falls. Insomnia was found to be a risk factor for falls in another study. Drug prescriptions for the elderly needed to be checked for quality. Inappropriate prescriptions were found with residents of nursing home residents. Statistical significance had been established in this study. Relevant information from other sources. The fall risk was not in correspondence with the falls; assessment of this was just a preventive measure (Fonad et al, 2008). Falls most certainly resulted in fractures. Other preventive measures were safety belts, wheelchairs, bed rails and avoiding sleeping pills. Sleeping pills with benzodiazepines were related (Fonad et al, 2008). Incontinence, postural hypotension and poor cerebral blood flow had been related to falls. A consequence was the fear of falling again. Neuro-epileptic drugs produced drowsiness or paranoia which triggered falls. Medication intensity was a problem. The fear of falls was a predictor as patients would limit their mobility and become less healthy gradually and later suffer from postural hypotension. Depression and the use of anti-depressants both caused falls. A risk assessment tool was needed to assess the risks of individual patients. The prevention could then be instituted (Fonad et al, 2008). Cognitive deficits and poor vision could also increase falls. Wheelchairs, bed rails and safety belts were good preventive measures. However these could cause more problems if the patients were agitated. Physical restraints should be instituted only with consideration winning the patient’s confidence and compliance (Fonad et al, 2008). The risk of a patient for falling could be determined by educating the staff about the intrinsic and extrinsic factors for falls (McCarter-Bayer, 2005). These included the disorders of mobility and balance, changed consciousness level and beliefs about the hospital environment. The age above 85 years, the physical disability associated with this age like kyphosis and gait problems and muscular weakness were also intrinsic factors for falls. Diseases, acute or chronic, produced more falls than in patients with cognitive deficits (McCarter-Bayer et al, 2005). Long hospitals stays, too much dependence for mobility and lack of exercise were conducive to falls. Medications had to be checked for dosage and quality. Anti-hypertensives, anti-depressants and narcotics could cause falls. Rapp indicated that residents of nursing homes were mainly of two groups: one had cognitive deficits, urinary incontinence and depression which made them at-risk patients (2008). Extrinsic factors included the patient being alone, absence of restraints, glossy slippery floors, lighting with too much glare and inadequate foot wear. Beasley also advocated a multifactorial approach for prevention (2009). The best evidence was to be utilized for the fall prevention. Though the means of prevention could vary, the essential technique for prevention was the awareness of the staff (Beasley, 2009). The JBI PACES program was found to be effective for producing change in an institution (Beasley, 2009). Hill investigated the resource utilization of patients by diagnosis-related groups in a retrospective observational research (2007). Orthopaedic falls over 3 years cost 127000 pounds in UK hospitals. Additional hospital stay of 12 days were found to have increased the costs in a US study; US $4233 was the extra cost of fallers than non-fallers, when matched for age, gender and admission time. The study was for inpatients only. Indirect costs like anxiety and stress experienced by patients and care-givers were not considered. Also the patient could have increased costs even after discharge. The important risk factors detected were cognitive disorders, stroke, Parkinson’s disease and history of serious falls (Hill, 2007). Hill concluded that falls were greater in certain diseases and with these illnesses, their hospital stay had the risk of being extended and the costs raised. Action (Summary) I had now reached the last part of Gibb’s Model in my research. Having collected plenty of relevant information, I decided that I was not going to wait for a fall. There were many things that I could start work on. My need at the moment was to be able to convince my colleagues and then the supervisor about the dire necessity of instituting changes in the wards and creating a new policy on prevention of falls. Once the supervisor was convinced, the policy makers in the hospital would be informed by the supervisor. My intention is to have the following implemented in the hospital. Selecting a multi-disciplinary approach to fall-prevention starting from planning was the first step. Awareness programme for the health professionals was to be instituted. The efforts must include the highlighting of the intrinsic and extrinsic factors. Identification of the patients at-risk and filling the tool for identifying risks of falls needed to be taught. The assessment could be checked by a senior staff. Preventable and non-preventable falls must be distinguished. Staff was not to feel responsible for all falls. Post fall assessments were equally significant. Interventions to make the environment friendly to the elderly were to be implemented. New non-skid footwear, fall alarms, wheelchairs, safety belts and bed rails as was individually needed, with some restraints, were helpful. Non-slippery floors and lighting with no glare were also important. Visible communication signs were to be put up for fall risk. Risk assessment was to be made a routine procedure with updating at every nurse shift. Illnesses were to be diagnosed and treated. Medications were to be checked for quality and dosage. Developing a suitable tool for the hospital was necessary. Patient contact was to be frequent for water and toileting assistance. Coloured armbands were to be used for identification for patients at risk. Fall investigative report was to be made after every fall to determine the cause and information shared with staff. Staff responsible must be further motivated to be careful. The success of prevention was to be reviewed every week. The efforts of the staff must be appreciated. Educating the families and patients on methods of fall prevention was significant in whichever circumstances they were living in. Further research to improve the fall prevention protocol was to be done. Conclusion Prevention of falls was possible in the elderly and it had to be planned with multidisciplinary and multifactorial approaches. Among the many problems that distressed the elderly, fall prevention had become a point of solace for the elderly. Precise planning and execution of the prevention protocol could be successful as evidenced by researches. The fall event in my ward was a starting point for my deep thinking and search for methods to prevent falls. The reflective process by Gibbs model helped me to achieve my objective References: Beasley, K. (2009). Benefits of implementing an interdisciplinary and multifactorial strategy to falls prevention in a rural, residential aged-care facility. Int J Evid Based Healthc 2009; 7: 187–192. doi:10.1111/j.1744-1609.2009.00136.x. Blackwell Publishing. Bergman SA, Olsson J, Carlsten A, Waern M, Fastbom J. Evaluation of the quality of drug therapy among elderly patients in nursing homes: A computerized pharmacy register analysis. Scand J Prim Health Care 2007;25: 9-14. Brooker, C. and Nicol, M. (2003). Nursing Adults: practice of caring. Elsevier Health Sciences Clemson,L., Manor, D. and Fitzgerald, M.H.( 2003). Behavioral Factors Contributing to Older Adults Falling in Public Places. OTJR: Occupation, Participation and Health. Volume 23, Number 3. Coughlan, M. Cronin, P. and Ryan, F. (2007). Step'by-step guide to critiquing research. 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