For this assignment we are required to locate a minimum of eight(8) secondary literature sources
that relates to a nursing issue topic. The Nursing issue chosen for this assignment is FALLS
PREVENTION; Preventing falls and harm from falls in older people
Clinical Practice Improvement Project Report
Hourly rounding reduces patient falls in elderly patient’s orthopaedic department.
The project aim of this study is to evaluate the effect of hourly rounding on patient fall rates in the
orthopaedic department. This is because several studies have established protocols that have
varying ranges of rounding’s, but the most commonly identified by evidence based practice are
hourly rounding’s. The project aims to integrate hourly rounding into the healthcare patient-fall
Relevance of Clinical Governance to your project
The concept of clinical governance is very important as it acts as an umbrella that covers the quality
care that is safe. The key pillars of CIP include patient focus, information focus, quality
improvement, staff focus and leadership. The effectiveness of an organization largely depends on
the contribution of each theme. The main focus on CIP is how these themes interact, which is
facilitated with the central role. The concept management of CIP are illustrated clearly by the
principles of nursing. This is important because these principles articulate what is expected in the
healthcare setting, irrespective of the healthcare provider and the stakeholders involved. The
proposed project highlights the four pillars of CIP in that it addresses the importance of integrating
individualised care to meet each patient individual needs (patient focus) (Goldsack et al., 2015).
Additionally, the project addresses the nurses pivotal contribution especially during communication
(information focus), and also emphasize the benefits of multidisciplinary and friendly working
environment (quality improvement). The project will also emphasize the value of effective
leadership skills in reducing patient-falls. The proposed project will ensure that patient hospital
stays, and the healthcare costs are reduced considerably. The proposed project will ensure that
patient access more integrated care, care that will ensure that people meets the demands and the
priorities of the community the healthcare community demands. The overall consequence is low
patient –fall rates, readmission rate, cost of care, lengthened hospital stays and improve patient
satisfaction and quality of life (Haines et al., 2013).
Evidence that the issue / problem is worth solving:
Patient falls is a great threat in public healthcare. The rates of patient’s falls are considerably high in
orthopaedic department, and especially among the elderly patients. This is attributable to the fact
that these patients are undergoing physiological changes such as poor eyesight, poor hearing
abilities, lower cognitive functions, poor balancing and increased muscle weakness and fatigue
(Hempel et al., 2013). Research indicates that hospital falls are the leading cause of mortality, and
lengthened hospital stays. Despite the numerous researches on this topic, numerous data are
continuing to be recorded because the strategies identified usually lack long term solutions
Patient falls among the elderly are the main source of non fatal injuries as well as trauma. Research
indicates that patient-falls rates correlate with the staffing ratio and organization safety culture.
The healthcare providers, especially the nurses are responsible for patient safety (Hutchings, Ward,
and Bloodworth, 2013). It is estimated that integration of evidence based practice in the healthcare
will reduce approximately, 1000 falls every month. In some nations, the concept of safe and quality
care is being emphasized too an extent that the public medical insurance fails to cater for hospital
costs associated with patient safety, claiming that these costs are preventable if the healthcare staff
practice EBP (Hicks, 2015).
Literature indicates that a lot of resources are wasted during the treatment of the hospital falls
rather than identifying the approaches that will strategize on minimizing the rates of hospital falls
(Rowe, 2012).This calls for a change of approaches by the healthcare providers, and to embrace the
innovative strategies that are identified by evidence based strategies to prevent patient falls. This
includes the use of assistance during toileting, use of fall assessment risks during admission and
integration of the healthcare providers in refresher training programs that are geared towards
reduction of patient falls in hospital setting (Kieke, 2014).
Stakeholders are very important especially when implementing change within an organization.
Understanding the impact of the proposed project in the organization will require understanding of
the types of stakeholders, and analysing how the proposed project will influence their interest.
Stakeholders are people within an organization who have something to lose or to gain through the
implementation of the proposed project. The stakeholder engagement is important as it effectively
elicit their views on the proposed project. This is important, particularly when conducting project
assessment. It is important to identify the external and internal stakeholders, the nature of each and
their influence in the proposed project (Trepanier & Hilsenbeck, 2014).
The internal stakeholders who will be involved in this project include clinical staff in the orthopaedic
department including the physician, general practitioners and the orthopaedic manager, whereas
the external stakeholders include the customers and the healthcare organizations that support safe
and quality care. The internal stakeholders in this project will be involved in funding, coordination
and resourcing of the proposed project (Olrich, Kalman, & Nigolian, 2012). The role of the external
stakeholders will be informed of advises based on their experiences and their views in addressing
the issue of patient falls. The engagement of these stakeholders is important as it facilitates in
decision making. This is because the stakeholders have values that important in the health care
facility. The integration the stakeholder addresses the negative perceptions and any source of
doubts regarding the policy changes (Lowel and Hudgson, 2012).
Plan-do-study-act (PDSA) offers effective cycles that can be used to evaluate the outcomes that
results from the proposed solution. This method is accepted in healthcare. The planning stage
involves setting of goals based on the patient demands. The Do stage is the implementation stage,
whereas the study stage involves the analysis of the outcomes. Act is the step conducted to ensure
that the improvements made are permanent (Dyck et al., 2013).
From this framework, the planning stage will involve intensive research to identify the healthcare
facility safety measures to identify the underlying gap that is causes increase in patient –fall rates.
This framework will facilitate in the process of identifying the conditions that precipitate the project,
the areas affected, and the people affected by the poor safety measures in the orthopaedic
department. This framework guides the exploration of the causes of this critical issue and the
characterization of the problem. The framework helps in the establishment of the baseline that will
be used to evaluate the outcome (Falls free, 2014). In this context, the number of injuries associated
with fall rates will be recorded before and after the implementation of the program. This data will be
used to examine the rates of readmission rates due to issues associated with patient-fall incidences,
and the additional cost of care due to lengthened hospital stays. This is proposed to take place for six
months. This short term project is aimed at providing conclusive decisions that can be applied in long
term strategies (Zephir, Minel, and Chapotot, 2011).
PEPPA refers to “participatory, evidence-informed, patient centred process for project
development, implementation and evaluation processes.” This framework outlines nine key steps
that will be used in this project. The first stage is to define the population and describe the present
patient safety measures in the organization. The next step will be to identify the relevant
stakeholders and the recruitment processes. The recruited stakeholders will participate in
discussions to identify the critical issues, which need to be addressed to improve the quality of care
(Trepanier, 2014). The fifth step is to define the strategic interventions that will address the critical
interventions that will fit within the healthcare facility goals and mission. The next step is planning of
the strategic implementation, including the identification of outcomes and the evaluation plan. The
facilitators and barriers of the project will also be identified. The plan (hourly rounding) will be
identified, evaluated and monitored (Graham, 2012).
Healthcare quality improvement requires a broad range of activities with varying level of complexity
in their methodological as well as the statistical rigor, which involves developing, implementation
and the assessment of the interventions proposed. All processes of improving quality in the health
care is geared towards achieving effective, safe, timely, efficient , patient centred and equitable
healthcare services (Trepanier, 2014).
Summary of proposed interventions:
The proposed intervention is to perform hourly rounding in the orthopaedic department. The
department ward will be divided into groups; the intervention group will have nurse perform hourly
rounding from 6 am to 10 pm in addition to the healthcare facility safety measure process. The other
ward will have only the tradition measures in place, which includes use of call lights, labelling of the
slippery floors and use of wrist bands indicating the high risk patients (Bennet et al.,2014).
Prior to the implementation process, the nurses and assistive nurses will undergo training on the
relevance of the proposed intervention. As stated previously, the hourly rounding will begin 6.00 am
to 11pm. After every rounding, the nurses in charge will fill in the log book provided. The log book
will indicate the patient admission date, reason for admission, patient fall incidence and any
other information relevant to hospital stays. The rounding will be routinely monitored by
managers, and will be supplemented by questionnaires filled by patients (Dykes et al., 2010).
After every two weeks, a formal meeting will be conducted. This will form the platform for the
nurses’ dilemmas and challenges during the implementation process are addressed. At the end of
the proposed project, 45 minutes focus group interview will be conducted. Data collected included
semi-structured interview as well as the use of questionnaires. This will ensure that the data is
explored holistically (Graham, 2012).
Barriers to implementation and sustaining change:
The possible barriers that would affect the proposed strategy will involve limited knowledge on
their expected of the nurse during the hourly rounding. There are challenges that there could be
under reporting of the proposed research. There is issue of organizational culture readiness. This is
because there is always some staff resistance to change, which could affect the study results and
conclusions. This should be addressed by assessing the organizational readiness.
Evaluation of the project:
The process of evaluation will be conducted to ensure that proposed intervention is sustainable.
This process is important because it indicates if the intervention outcomes have beneficial or
adverse effects. In this context, the evaluation process will be done after the implementation of the
project. Additionally, the evaluation process will be done after every twelve months after the
initiation of the study. However, it is important to note that the interventions outcomes may not be
realised immediately. This is because it takes some time before change is accepted, integrated in the
organization and realization of the outcomes (Baker, 2014).
The evaluation process will be conducted using questionnaire and patient’s feedback. The
questionnaires will be structured in a way that it appraises the patient’s perceptions on threats and
vulnerability associated with patient falls. It will also assess the patient healthcare relation and
interaction to evaluate on how it impacts patient falls.
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