NURS2006 ASSIGNMENT 3

Clinical Practice Improvement Project Report

Student Name, FAN and ID:

Lovely Zagade zaga0003 2159291

Project Title:
Identification of effective strategies to prevent elderly falls in hospital
and community caused by hypertension, antihypertensive medications
and orthostatic hypotension
Project Aim:
The aim of the project is to, first, investigate the relationship between
hypertension, orthostatic hypertension and antihypertensive medications, and
elderly falls in hospital and community on a two-month time frame. The study
then aims to propose effective and relevant interventions having the tendency of
reducing the morbidity of elderly people associated with falls, hence, improving
the overall quality of general health.
Relevance of Clinical Governance to your project
According to Jaggs-Fowler (2011, p. 592), an action or manner in which an
organisation conducts its affairs in accordance with some prescribed set of rules,
principles and standards is known as Governance. Clinical Governance is
considered as one of the two globally accepted pillars of governance taking into
account the delivery of modern health care. The second pillar is financial
governance, however, it is advocated by Bem (2010, p. 475) that social
governance is the third pillar. Clinical governance is responsible for the
implementation of such strategies resulting in improving the quality of care
provided, encompasses the supervision of various clinical standards and ensures
that doctors, or any healthcare professional, is accountable for their professional
actions (Jaggs-Fowler 2011, p. 592). Analysing this definition reveals two
important characteristics of clinical governance, namely, accountability and
quality. Both of the features are equally important and have a momentous role
to play in the delivery of quality health care. Before analysing the relevance of
clinical governance to this project, the pillars of clinical governance must be
presented. Though widely believed that there are seven pillars of clinical
governance (Peyrovi, Nasrabadi and Valiee 2016, p. 216; Azmal et al. 2016, p.
2507), Jaggs-Fowler (2011, p. 593) outlined ten facets/pillars of clinical
governance, arguing that each is of equal importance. The pillars namely, (i)
propagation of innovative ideas and good practice, (ii) record keeping of high-
quality data, (iii) evidence-based practice (EBP), (iv) leadership, (v) clinical risk
reduction, (vi) detection of adverse events, (vii) realising lessons from
complaints, (viii) addressing inadequate clinical performance, (ix) quality
improvement including clinical audit, and (x) professional development
programmes. This project is closely related to the quality improvement including
clinical audit pillar of clinical governance as Dixon (2013, p. 357) mentioned that
clinical audit, in itself, is meant to be a systematic process of quality
improvement which measures and then improve the quality of care.
Subsequently, the primary aim of this project is to identify such strategies which
can reduce elderly falls, ultimately leading to the delivery of quality health care,
hence, covering one of the primary pillars of clinical governance. According to
Callisaya et al. (2014, p, 1531) a higher dose of antihypertensive medications
results in increased risk of falls in elderly people (whether in hospital or
community settings); relating it with the pillar of clinical governance, namely
clinical risk reduction, this project aims to identify whether antihypertensive
medications and other factors are associated with elderly falls to implement
preventive measures, hence, aiming to reduce the clinical risks of harms to the
patient by such drugs and ultimately elderly falls. The identified links between
the project and the two pillars of clinical governance (discussed above) are
closely linked with the professional development of healthcare professionals
(another pillar of clinical governance) as this project aims to ensure that poor
performance in clinical settings is addressed and the healthcare professionals are
learning from their mistakes so that elderly falls can be reduced and quality of
healthcare can be improved (Jaggs-Fowler 2011, p. 594). Clinical governance also
focuses on Evidence-Based Practice (EBP) and the aim of this project to identify
effective interventions for reducing elderly falls is also linked with this pillar as
Doran et al. (2014, p. 274) mentioned that nursing interventions based on EBP
have proved to be effective in reducing falls in elderly people. The project is also
linked with other pillars of clinical governance but because of the scope and
limitations of this study they are not discussed in detail and focuses only on the
important ones and those studied during the course of study.
Evidence that the issue / problem is worth solving:
Gangavati et al. (2011, p. 383) mentioned that the major cause of disability in
elderly people is falls. Callisaya et al. (2011, p. 481) reported that more than
30% of elderly people living in the community fall each year and as a consequent
it leads to critical injuries, such as hip fractures, having significant economic,
social and health costs (Callisaya et al. 2014, p. 1527). Falls are considered as a
major health problem for elderly people, whether hospitalised or living in a
particular community and due to the ageing of populations, the costs associated
with falls is rapidly increasing (Callisaya et al. 2011, p. 482). Costa et al. (2012, p.
1) pointed out that increased health care costs and prolonged rehabilitation
period are one of the complications of fall-related injuries and accounts for
around 32.3% of all the reported incidents regarding falls. In the same context,
Bradley (2013, p. vi) highlighted that approximately 83,800 cases of falls in
elderly people, aged between 60 and higher, were reported in Australia during
2009-10. Further, 70% of these hospitalised cases occurred either in an aged
care facility or homes (Bradley 2013, p. vi) and have incurred around $4913 AUD
per fall to the healthcare associations in Australia (Heslop and Wynaden 2015, p.
3). This discussion covers one part of the project i.e. provides evidence on why it
is important to implement falls preventive measures in elderly people.

Berry and Douglas (2014, p. 596), during their review of the literature, found that
findings from various studies have suggested that use of antihypertensive
medication is associated with injurious and increased elderly falls, whether it be
a hospital or community-based setting. The authors further highlighted that
underlying hypertension (reason for taking antihypertensive medications) also
results in injurious elderly falls an alternate possibility. It is because of the fact
that individuals or elders treated for hypertension may possess more comorbid
conditions or vascular disease that increases the risk of falls. In the same
context, Butt and Harvey (2016, p. 600) mentioned that patients with
hypertension are more prone to orthostatic hypertension and as a consequent
are at an increased risk of fractures and/or falls following the initiation of
antihypertensive drugs. This clearly indicates that hypertension, orthostatic
hypertension and antihypertensive medications results in injurious elderly falls,
therefore, it is necessary to implement effective interventions which can reduce
injurious falls resulting from these and will improve the overall quality of
healthcare.
Key Stakeholders:
Registered Nurses (RN)

Wilson et al. (2016, p. 1013) mentioned that nurses have an important to play in
the formulation and implementation of fall preventive interventions, however,
little evidence exists suggesting that nurses are aware of evidence-based fall
prevention interventions and the strategies to improve these. Therefore, nurses
are perceived to be one of the important stakeholders of this project in terms of
professional and personal development regarding the implementation of
evidence-based fall prevention interventions.

Patients and their families (carers)

Falls have already claimed the lives of many elderly people in Australia (Heslop
and Wynaden 2016, p. 3). Siracuse et al. (2012, p. 335) indicated that elderly
people are at a higher risk for injury to the pelvis, neck and head due to falls.
Similarly, the caregivers of elderly people who can withstand falls must take the
initiative to implement proper treatment plans for their loved ones, as a matter
of fact informal caregivers/carers (family and friends) provides the most long-
term care services rather than any formal caregiver (nurses) (Katz and Shah
2010, p. 273).

Physiotherapist

Physiotherapists, as considered experts in movement and exercise, can help in

significantly reducing falls in elderly people (Martin et al. 2013, p. 183).
Physiotherapists helps in designing such interventions (based on exercises)
which can potentially reduce the risks and injuries related to falls through
conducting home-based programs with the individuals, offering group programs
in community or hospital settings, and raising the awareness of community
through educating them about the importance of regular exercise in falls
prevention (Sherrington and Tiedemann 2015, p. 59).

Occupational Therapist

Leland et al. (2012, p. 149) mentioned that the therapists of occupational

therapy are exclusively qualified to cater falls having a multifactorial nature
provided that they have exceptional knowledge that influences their occupational
performance. The authors (p. 158) further mentioned that occupational therapist
(OP) helps in reducing falls with the help of exercise,
multifactorial/multicomponent modifications and interventions regarding
environmental modifications, hence, OPs having a strong relationship with this
project.
CPI Tool:
Hwang, Wen and Chen (2010, p. 1262) mentioned that the PDSA cycle,
constituting of Plan, Do, Study and Act phases is a methodology used for
improvements in various processes on the basis that improvement comes from
the application of knowledge. This cycle is used in a number of Clinical Practice
Improvement (CPI) projects and has been deployed by this study to effectively
execute the project. The first two phases of the cycle, Plan and Do, will be used
to plan and carry out the change and the last two phases, Study and Act, will be
used for evaluating the outcomes of the project so that definitive
recommendations can be proposed.

Plan-Do: The project aim is to investigate the relationship and association

between hypertension, orthostatic hypotension and antihypertensive medication,
and falls in elderly people in the hospital and community-based settings. To
achieve the objective, it is planned that an observational study will be conducted
with a sample size of 60 elderly people 30 in hospital settings and 30 in
community settings with age more than 65 years. A thorough research will be
conducted and some effective interventions to reduce elderly falls, also including
the factors of hypertension, orthostatic hypotension and hypertensive
medication, will be formulated and implemented. The interventions will, then, be
applied on 15 hospitalised patients and 15 patients living in the community
either with their friends or family. The behaviour and the routine life of the 30
patients (to whom the interventions will be given) will be compared with that of
remaining 30 patients to whom the interventions will not be provided to observe
the number of falls on a three-month time period. This will result in the
measurement of the effectiveness of the proposed interventions and it is
hypothesised that the proposed interventions (discussed in the next section) will
prove to be beneficial in reducing elderly falls. In order to observe the behaviours
of the patients after the interventions will be given, video recording will be used
in hospitalised settings so that real-time falls and causes for falls can be analysed
as also done by Robinovitch et al. (2013, p. 47). However, for the elderly patients
living in a community-based setting, a video camera cannot be used because of
ethical considerations and as a consequent the help of volunteers will be taken
(prior to the permission of elderly patients and their families) to live with the
patients and observe their behaviours.
Summary of proposed interventions:
Other than hypertension, orthostatic hypotension and the use of hypertensive
medications, there also exists a variety of causes for elderly falls, whether in a
hospital or community-based setting. Robinovitch et al. (2013, p. 51) found that
the biggest cause of falls in elderly people is due to the incorrect shifting of
weight followed by three major classes of activities, namely, walking, sitting
down and standing. Therefore, it is evident that the proposed interventions must
cater these causes while performing the fall risk assessment and implementing
the prevention strategies.

Martin et al. (2013, p. 182) argued that groups based exercise are found to be
effective in reducing the number of falls in elderly people, enhances the quality
of life and offers improvements over the traditional home-based exercises. The
authors further argued that a physiotherapist also have an important role to play
in reducing the number of falls and during their systematic review, it was found
that when physiotherapist-recommended exercises were integrated with group
exercises, the quality of life and some physical functioning measures of the
patients were improved. Further, Neyens et al. (2011, p. 411) advocated that the
assessment of hazards in the home and modifications by a healthcare
professional also have the potential to reduce elderly falls. Hill and Wee (2012,
pp. 26-27) discussed that antidepressant and patients of hypertension and/or
orthostatic hypertension taking antihypertensive medications are at an increased
risk of falls and for that, a significant amount of literature suggests that the use
of these drugs can be reduced using non-psychotropic pharmacological
interventions and non-pharmacological approaches. However, if the use of
antihypertensive medications (psychotropic drugs) is necessarily required, then
the patients must be closely monitored by a fall risk assessment and attempts
must be made to reduce or completely cease the use of such medications. Hill
and Wee (2012, p. 25) mentioned that falls are multifactorial in nature and
proposed some falls risk assessment tools to be used for elderly people in
community and hospital-based setting, including Falls Risk for Older People
(Community settings, FROP-Com) and Physiological Profile Assessment (PFA) of
the patients to identify specific risk of falls targeted on individual patients. Lastly,
some interventions proposed by the Australian Commission on Safety and Quality
in Healthcare (2009, p. xix) will be utilised along with the aforementioned ones to
reduce falls and their consequences. Calcium and Vitamin D supplementations
should be given to the elderly peoples living in the community as an intervention
strategy to prevent falls provided they are exposed to the minimum levels of
sunlight. Group exercises must be recommended along with home safety and
education interventions, such as the Stepping on Program, to reduce falls in
elderly people living in the community. And, multifactorial interventions must be
utilised for individual elders (for both hospital and community-based settings)
including individualised assessments directly leading towards the implementation
of effective interventions (ACSQHC 2009, p. xix).
Barriers to implementation and sustaining change:
As the project involves the use of video camera and volunteers to monitor the
behaviour of patients during interventions, it may raise certain privacy concerns
because not all of the patients or their families are comfortable with their
consistent monitoring whether it be in the hospital or community-based settings.
However, Lee, Heilig and White (2012, p. 38) highlighted that the patient health
surveillance necessarily occurs without the consent of the patient and is ethically
justifiable under public health ethics and principles of contemporary clinical
ethics. Further, the use of volunteers and surveillance of patients with video
cameras will incur additional costs which may act as a barrier to the
implementation of this project. Child et al. (2012, p. 12) highlighted some of the
important barriers to the implementation of fall prevention strategies and
mentioned that not every group exercise or recommendations from a
physiotherapist or occupational therapist may prove to be beneficial for
individual patients. Specifically, the type of the intervention, whether it be an
exercise, must be tailored to the needs of individual preferences as it is possible
that some patients may prefer individual exercise at home, or with groups.
Further, the choice of a patient in accepting an intervention is completely
dependent on the psychological and physiological influences of the intervention
followed by the cultural and social structures in which the particular patient is
living (Child et al. 2012, p. 12). Lastly, but not the least, the compliance of the
patient towards any fall-prevention intervention is crucial for the success of
aforementioned interventions and for that the healthcare professionals must
make older people aware of the consequences of falls while avoiding any denial
from their side.
Evaluation of the project:
Study and Act: The project will be evaluated through taking into account the
number of falls per person on a three-month period to whom the interventions
will be given and will be compared with the number of falls per person to whom
the interventions will not be given. After every one month of the intervention,
retrospective charts will be made after conducting a fall risk assessment of
individual patients and will be audited to measure the number of falls. For
example, if the number of falls per person before the interventions were 10 (on
monthly average) and after the implementation of the interventions it reduced to
5 per person (monthly average) then the project will be successful in reducing
the number of falls in elderly people taking antihypertensive medications due to
hypertension and orthostatic hypotension. However, if the results are not in line
with the assumptions/hypothesis, the study will then review the interventions
again to identify major flaws to be removed. The behaviour of the patients
towards the fall intervention strategies will also help in evaluating the outcomes
of this project, for instance if more than 25 patients are responding positively
towards the interventions, provided the results are also positive, then it can be
said that the proposed interventions are effective and future studies must
analyse further robust interventions tailored to individual preferences in order to
reduce falls in elderly people.
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 NURS2006 Assignment 3 - CPI paper Marking Rubric

PERFORMANCE STANDARD
CATEGORY
& Excellent Work Good Work Passing Work Unsatisfactory
WEIGHTING work

Aim succinct & Aim well defined. Aim stated with some Aim not clearly stated
Project Aim clearly Some irrelevant ambiguity. Some Most evidence is not
and defined. All evidence information but most evidence relevant relevant or rigorous.
Evidence relevant & rigorous. evidence relevant & and rigorous, Poor level of insight &
the issue is Shows a very high rigorous. Shows a Acceptable level of relevance to the
worth level of insight & very good level of insight. issue. Significant
solving relevance to the insight & relevance to Quite a lot of amount of irrelevant/
20% issue. the issue. irrelevant information missing information.
is present. May be (09.5)
(13-16.5) overlong/ too brief

(17-20) (10-12.5)

Succinct and highly Succinct and mostly Adequate discussion Inadequate

Relevance relevant discussion of relevant discussion of of the relevant pillar discussion of the
of Clinical the relevant pillar of the relevant pillar of of clinical governance relevant pillar of
Governance clinical governance clinical governance related to the chosen clinical governance
to your related to the chosen related to the chosen clinical issue. related to the chosen
project clinical issue. clinical issue. Some parts not clinical issue.
relevant Overlong / Overlong / too brief,
10% too brief, may be may be missing a
missing relevant significant amount of
(9-10) (7-8.5) information. relevant information
(5-6.5) (0-4.5)
Identifies most Identifies some Identifies a few Contains irrelevant
Key relevant key relevant key relevant key information, or major
Stakeholde stakeholders. stakeholders and stakeholders. information is
rs Discusses clearly how adequately discusses Mentions briefly how missing.
5% they could be how they could be they could be Inappropriate or no
involved in the involved in the involved. Quite well key stakeholders are
project. project. written but contains identified Poor insight
Succinctly and Very well written. some irrelevant into the stakeholder
expertly written. Very Good level of insight information, or minor role.
high level of insight into the role of information is
into the role of stakeholders. missing. Adequate
stakeholders. level of insight into
the stakeholder role. (0-2)
(4.5 - 5) (3.5-4.25) (2.5 3.25- )

Describes a relevant Describes a relevant Describes a relevant A relevant CPI tool is

Clinical CPI tool Very clearly CPI tool Discusses CPI tool and not identified. There
Practice discusses how it quite clearly how the adequately discusses is no adequate
Improveme could be used to tool could be used to how the tool could be discussion of how the
nt Tool address the aim and address the aim and used to address the tool could be used to
20% implement the implement the aim and implement meet the aim or
interventions. interventions. Well the interventions. implement the
Succinctly and written but may Not succinct, contains interventions.
expertly written with contain some irrelevant Contains irrelevant
no omissions of irrelevant information, information or some
relevant information. information, or some significant major information is
minor information is information is missing missing.
(17-20) missing (10-12.5) (09.5)
(13-16.5)
All relevant Most relevant Acceptable level of Some elements
Summary interventions are interventions relevant interventions missing or
of discussed very well. discussed quite well. discussed. incomplete. May
proposed Project outline is very Project outline is Project outline mostly contain large
interventio clear and the clear & relevance to clear, although it may amounts of irrelevant
ns relevance to clinical clinical practice is be unclear how the information.
20% practice is very high. good. Contains some project would actually Project poorly
irrelevant be implemented in described and it is
information, minor clinical practice due unclear what the
information may be to irrelevant/missing project actually
missing. info entails or its
relevance to clinical
(17-20) (13-16.5) (10-12.5) practice.

(09.5)
Identifies most Identifies some Identifies a few Relevant barriers not
Barriers to potential barriers to potential barriers to potential barriers to identified. Poor or no
Implementa implementation & implementation & implementation & discussion about how
tion clinical change. clinical change. clinical change. they could be
15% Discusses in depth Discusses how these Discusses how overcome or
how these barriers barriers could be barriers could be minimised. Major
could be overcome or overcome or overcome or omissions, much of
minimised. minimised. minimised. Minor the information
omissions and/or provided is
some irrelevant irrelevant / unrelated
information present to the CPI goal.
(13-15) (10-12.5) (7.5-9.5) (0-7)
Succinct discussion of Succinct discussion of Discussion of an Plan absent or not
Evaluation an excellent and a very good and adequate plan for well described. Most
of the achievable plan for mostly achievable how the or all of the plan is
project how the plan for how the intervention/s could not relevant or
10% intervention/s could intervention/s could be evaluated. Some achievable
be evaluated. be evaluated. parts not relevant or Overlong / too brief,
achievable may be missing a
Overlong / too brief, significant amount of
may be missing relevant information
relevant information.
(9-10) (7-8.5) (0-4.5)
(5-6.5)

Name of Marker

Grade

Overall Comments