NRS 493 Benchmark – Capstone Project Change Proposal – BSN Capstone Project Example

NRS 493 Benchmark – Capstone Project Change Proposal

Capstone Project Change Proposal: Demonstration-based nurse training and patient education to prevent and reduce falls among Alzheimer’s patients

Capstone Project Change Proposal

Alzheimer’s disease is a progressive neurologic disorder characterized by the death of brain cells and brain atrophy (CDC, 2020). The condition results in a progressive decline in cognitive ability and associated behavioral and social skills. Alzheimer’s disease affects bodily functions and is common among individuals aged 65 years and above. With reduced body functions due to old age, cognitive impairment increases the risks of falls among the geriatric population.

Over 6 million Americans aged ≥ 65 have been diagnosed with Alzheimer’s dementia as of 2021 (Alzheimer’s Association, 2021). This number has increased by 16% in the past year, and it is estimated that over 12 million Americans will be diagnosed with Alzheimer’s disease by 2050 despite the scientific development of its prevention or cure. The burden of management of the falls directly on families and healthcare providers. Patient falls increase the burden and lowers the quality of life. Therefore, establishing a prevention and reduction mechanism is crucial for managing Alzheimer’s disease among individuals.

Background

Falls among geriatric Alzheimer’s patients are complex and are considered a multifactorial clinical problem that often results in significant mortality and morbidity among victims. Approximately $31 billion is spent annually on direct medical care costs from patient falls (Burns, Stevens, & Lee, 2016). In addition, more than 1 million inpatients fall yearly, while those in long-term care facilities are considered to have higher risks of falling (Agency for Healthcare Research and Quality, 2019). An understanding and knowledge of evidence-based practices (EBP) can enhance an institution’s and nurses’ capacity to establish effective and efficient programs that promote the patient’s rights to safe and quality care (ANA, 2015).

The limited evidence-based knowledge on fall prevention among nursing staff also contributes to the high incidences of patient falls within the organization affecting the quality and safety of the resident care. Equally, having mental impairment in the form of Alzheimer’s exacerbates the frequency and nature of these falls. Mentally ill patients have greater falling risks than those without mental illness (Fernando et al., 2017). This proposal proposes a demonstration-based nurse training and patient education to prevent and reduce falls among Alzheimer’s patients.

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Problem Statement.

The central issue affecting the organization’s need to address an evidence-based nursing practice solution is inadequate knowledge on evidence-based practice for fall prevention amongst Alzheimer’s patients. As a result, the nursing staff does not implement effective fall prevention strategies during care delivery. Consequently, the rate of patient falls among Alzheimer’s patients have significantly increased.

Proposal Purpose

This project proposes training of nurses and educating patients on how to prevent and reduce patient falls. The training module is adapted from the Agency for Healthcare Research and Quality (See Table 1). As a result, the project will contribute to establishing an interactive education system as the first step in addressing and resolving the preliminary research and evidence-based practice gap. Research and evidence-based practice knowledge are crucial in ensuring patient safety (Horntvedt et al., 2018). Evidence-based practices facilitate effective implementation of the most relevant and available evidence to support nursing interventions while involving a patient in their treatment plan as much as possible. Typically, evidence-based practice enables nurses to evaluate the research to identify risks and effectiveness of various intervention measures. Because of this, knowledge of research and evidence-based practice can help nurses facilitate patient education on falling risks, thus preventing future occurrences.

Resource Name	Resource Description
Agency for Healthcare Research and Quality https://www.ahrq.gov/patient-safety/settings/hospital/fall-prevention/index.html	The AHRQ developed the Fall Prevention in Hospitals Training Program to support the training of hospital staff on how to implement AHRQ’s Preventing Falls in Hospitals Toolkit. https://www.ahrq.gov/sites/default/files/publications2/files/fallpxtoolkit-update.pdf

Table 1: Fall prevention education material (Adopted from AHRQ)

PICOT Question.

For Alzheimer’s patients in a mental health care facility, will demonstration-based nurse training and patient education compared to no nurse training and patient education prevent and reduce falls in three months?

Literature Search Strategy

The search was carried via the GCU library service. The GCU library provides access to several reputable scholarly databases from which a student can access resources for various assignments. The CINAHL and Cochrane Library databases were searched for full-text fall prevention and reduction articles among Alzheimer’s patients. The database provides broad and easy access to top nursing journals, including full-text articles and peer-reviewed and evidence-based research. The search strategy adopted key search terms likely to appear in research articles or medical subject headings. Search terms such as “fall prevention,” “Alzheimer’s patients,” or “evidence-based practices for fall prevention among Alzheimer’s patients.”

Literature Evaluation

Patient fall can cause injuries, including bruises or hip fractures, and death among elderly patients with dementia (Hartholt et al., 2019). Falls also contribute to increased morbidity, healthcare costs, and some instances, mortality. Nevertheless, studies have identified fall risks among dementia and elderly patients. Pirrie et al. (2020) argued that low consumption of fruit and vegetables increases the risks of falls among older adults. Equally, Calcium and Vitamin D supplements improve bone health (Guirguis-Blake et al., 2018). Fernando et al. (2017) identified risk factors of falls associated with demography, limited balance and gait, impaired vision, reduced functional status, antipsychotic medications, and the severity of dementia. Fernando et al. (2017) further argue that verbal disruption, visual complications, cortical changes, dementia severity, and attention-seeking demeanor are factors unique to the dementia population that contribute to risks of falls.  

 Studies have endorsed various EBP practices for fall prevention among dementia and elderly patients in community-dwelling and clinical settings. According to Gill et al. (2016), multifactorial and exercise interventions can reduce fall risks. For example, patient education programs have shown a higher impact on fall reduction than an organized physical activity program (Gill et al., 2016). Other interventions for fall prevention include patient education, educational tools and materials, hospital policies and procedures (Heng et al., 2020). 

However, there is insufficient evidence on effective fall prevention and reduction practices for dementia patients (Peek et al., 2020). The paper found limited evidence on appropriate fall prevention and reduction among dementia patients, and the existing evidence provides insufficient information. Altogether, these findings support the need for further research to guide evidence-based interventions for fall prevention guidelines among individuals with cognitive impairment.

Nursing Theory

Lewin’s theory makes the most sense in implementing the proposed demonstration-based nursing training on preventing and reducing falls among Alzheimer’s’ patients in a mental health care facility. The theory is founded on the premise that change behavior results from antagonistic forces, which push employees towards the desired direction while inhibiting forces that might hamper changes (Mitchell, 2013). Lewin’s theory consist of three steps, i.e., unfreezing, moving, and refreezing. Unfreezing phase involves altering exiting behavior/status quo, which is inadequate knowledge of EBP on fall prevention and reduction. The moving step involves initiating the changes, i.e., carrying out demonstration-based nurse training on effective ways to mitigate patient fall problems. Lastly, refreezing involves establishing equilibrium with newly adopted behaviors to handle EBP and patient education.

Implementation Plan and Outcome Measures

The project team will first establish a fall-prevention education guideline for nurses and patients. Then, the project team will evaluate patients’ and nurses’ awareness and knowledge of evidence-based fall prevention practices using open-ended questionnaire surveys. Nurse educators will then train nurses on evidence-based fall prevention practices, while the nurses will contribute to patient education.

The project goals are to reduce the number of falls among geriatric Alzheimer’s patients, fall-related injuries, readmission, prolonged hospitalization, and operation cost incurred from medication and hospitalization within the mental health facility. In this regard, the outcome measures for the project include an established framework for routine nurse training and patient education on evidence-based fall prevention strategies, awareness of fall prevention strategies among patients and nurses, and change in the rate of falls.

EBP on Fall Intervention Plan

There is insufficient evidence-based literature endorsing crucial fall prevention and reduction measures for dementia patients in any care setting (Peek et al., 2020; Bunn et al., 2014). An understanding and knowledge of EBP on fall prevention and reduction would enhance the nurses’ capacity to contribute to initiatives aimed at promoting patients’ rights to quality and safe care (American Nurses Association (ANA), 2015). Thus, an interactive demonstration-based nurse training, patient education, and the associated outcomes will guide appropriate EBP for fall prevention and reduction.

Evaluation Plan

The Lewis change model will be used to implement the change model within the facility. The critical evaluation points will be the change proposal goals. A crucial evaluation model allows researchers to understand the objective world and assess the value of the nursing intervention (Cheng et al., 2017). As a result, the evaluation team will determine nursing staff awareness of fall problems among Alzheimer’s patients and EBP in preventing and reducing these falls. Nurses’ knowledge of EBP on fall prevention among Alzheimer’s patients will be equally evaluated following nursing training. Lastly, the evaluation team will determine established fall prevention measures.

The evaluation team will use a goal-based evaluation design to assess proposal goal attainment. In this regard, the evaluation team will seek to answer the following questions: Are nurses aware of fall problems among Alzheimer’s patients and appropriate EBP on fall prevention? Are nurses knowledgeable about EBP on fall prevention among Alzheimer’s patients? Are there established EBP or guidelines for fall prevention? (See Survey Questionnaire I). Evaluation of nurses’ perspectives and research findings are necessary to establish the intervention benefits and the efficacy of the research team (Rørtveit et al., 2020).

Therefore, the research team will use open-ended interview questionnaires to collect data on nurses’ perception of the proposed intervention, awareness, and knowledge of fall prevention EBP (See Survey Questionnaire I and II). Moreover, data from hospital records will be accessed for comparison analysis of rates of falls before and after the change proposal intervention (See Table 2). An effective data collection facilitates the practical evaluation of research outcomes (Halcomb & James, 2019).

Table 1: Evaluation of Intervention Success

Intervention	Yes	No	Remarks
Modified Environment
Patient Education
Risk Signs
Hip Protectors
Bedrails
Toileting Reminders
Movement Reminders
Exercise Program
Post Fall Response Plan

Adapted from Oliver et al. (2010)

Barriers to Project Implementation

The potential barrier to the project implementation is the institution’s culture that is resistant to change. Culture has a significant impact on clinical processes and, ultimately, patient health and safety (Mannion & Davies, 2018). Culture also influences the leadership and happiness of healthcare personnel. An assessment of culture within the mental health care facility revealed a lack of nursing education programs in using EBP for fall prevention and reduction in Alzheimer’s patients and a nursing culture that is resistant to change. Resistance to change could be overcome by adopting the Lewis change model theory to allow the project team to assess, evaluate, and mitigate participants’ perceptions that could limit the project implementation.

References

Agency for Healthcare Research and Quality. (2019). Falls. Retrieved 6 August 2021, from https://psnet.ahrq.gov/primer/falls

Alzheimer’s Association. (2021). Alzheimer’s disease facts and figures. Retrieved 25 September 2021, from https://www.alz.org/media/Documents/alzheimers-facts-and-figures.pdf

American Nurses Association. (2015). Code of ethics for nurses with interpretive statements. Silver Spring, MD: Author.

Bunn, F., Dickinson, A., Simpson, C., Narayanan, V., Humphrey, D., Griffiths, C., … & Victor, C. (2014). Preventing falls among older people with mental health problems: a systematic review. BMC Nursing, 13(1), 1-15. https://doi.org/10.1186/1472-6955-13-4

Burns, E. R., Stevens, J. A., & Lee, R. (2016). The direct costs of fatal and non-fatal falls among older adults—United States. Journal of Safety Research, 58, 99-103. 10.1016/j.jsr.2016.05.001

Centers for Disease Control and Prevention. (October 2020). Alzheimer’s Disease and Related Dementias. Retrieved 25 September 2021, from https://www.cdc.gov/aging/aginginfo/alzheimers.htm

Cheng, J. L., Chu, Y. P., Han, S. F., Li, Y. J., & Tan, Q. (2017). Research and perspectives on criteria for evaluation of nursing research achievements. Chinese Nursing Research, 4(3), 107-112. https://doi.org/10.1016/j.cnre.2017.06.001

Cochrane Library. (n.d.). About the Cochrane Library. Retrieved 3 August 2021, from https://www.cochranelibrary.com/

Fernando, E., Fraser, M., Hendriksen, J., Kim, C. H., & Muir-Hunter, S. W. (2017). Risk factors associated with falls in older adults with dementia: a systematic review. Physiotherapy Canada, 69(2), 161-170. https://dx.doi.org/10.3138%2Fptc.2016-14

Gill, T. M., Pahor, M., Guralnik, J. M., McDermott, M. M., King, A. C., Buford, T. W., … & Miller, M. E. (2016). Effect of structured physical activity on prevention of serious fall injuries in adults aged 70-89: randomized clinical trial (LIFE Study). BMJ, 352. https://doi.org/10.1136/bmj.i245   

Guirguis-Blake, J. M., Michael, Y. L., Perdue, L. A., Coppola, E. L., & Beil, T. L. (2018). Interventions to prevent falls in older adults: updated evidence report and systematic review for the US Preventive Services Task Force. JAMA, 319(16), 1705-1716. https://doi.org/10.1001/jama.2017.21962

Halcomb, E., & James, S. (2019). Collecting data in research: How careful planning can ensure fewer problems are encountered in data collection. Nurse Researcher, 27(2), 6-7. 10.7748/nr.27.2.6.s2

Hartholt, K. A., Lee, R., Burns, E. R., & Van Beeck, E. F. (2019). Mortality from falls among US adults aged 75 years or older, 2000-2016. JAMA, 321(21), 2131-2133. https://doi.org/10.1001/jama.2019.4185 

Heng, H., Jazayeri, D., Shaw, L., Kiegaldie, D., Hill, A. M., & Morris, M. E. (2020). Hospital falls prevention with patient education: a scoping review. BMC geriatrics, 20(1), 1-12.

Heng, H., Jazayeri, D., Shaw, L., Kiegaldie, D., Hill, A. M., & Morris, M. E. (2020). Hospital falls prevention with patient education: a scoping review. BMC Geriatrics, 20(1), 1-12. https://doi.org/10.1186/s12877-020-01515-w

Mannion, R., & Davies, H. (2018). Understanding organizational culture for healthcare quality improvement. BMJ, 363. https://doi.org/10.1136/bmj.k4907

Mannion, R., & Davies, H. (2018). Understanding organizational culture for healthcare quality improvement. BMJ, 363. https://doi.org/10.1136/bmj.k4907

Mitchell, G. (2013). Selecting the best theory to implement planned change. Nursing Management, 20(1). https://doi.org/10.7748/nm2013.04.20.1.32.e1013

Oliver, D., Healey, F., & Haines, T. P. (2010). Preventing falls and fall-related injuries in hospitals. Clinics in geriatric medicine, 26(4), 645-692. https://doi.org/10.1016/j.cger.2010.06.005

Peek, K., Bryant, J., Carey, M., Dodd, N., Freund, M., Lawson, S., & Meyer, C. (2020). Reducing falls among people living with dementia: A systematic review. Dementia, 19(5), 1621-1640. https://doi.org/10.1177/1471301218803201  

Pirrie, M., Saini, G., Angeles, R., Marzanek, F., Parascandalo, J., & Agarwal, G. (2020). Risk of falls and fear of falling in older adults residing in public housing in Ontario, Canada: findings from a multisite observational study. BMC Geriatrics, 20(1), 1-8. https://doi.org/10.1186/s12877-019-1399-1

Rørtveit, K., Saetre Hansen, B., Joa, I., Lode, K., & Severinsson, E. (2020). Qualitative evaluation in nursing interventions—A review of the literature. Nursing Open, 7(5), 1285-1298. https://doi.org/10.1002/nop2.519

Appendix A

Table 1: Education Material

Resource Name	Resource Description
Agency for Healthcare Research and Quality https://www.ahrq.gov/patient-safety/settings/hospital/fall-prevention/index.html	The AHRQ developed the Fall Prevention in Hospitals Training Program to support the training of hospital staff on how to implement AHRQ’s Preventing Falls in Hospitals Toolkit. https://www.ahrq.gov/sites/default/files/publications2/files/fallpxtoolkit-update.pdf

Table 1: Evaluation of Intervention Success

Intervention	Yes	No	Remarks
Modified Environment
Patient Education
Risk Signs
Hip Protectors
Bedrails
Toileting Reminders
Movement Reminders
Exercise Program
Post Fall Response Plan
Reduced Fall Rates

Appendix B

Survey I

1. Are you aware of the fall risks that Alzheimer’s patients are facing within the facility?

1. If yes, explain why?
2. What are some of the fall risk prevention practices do you currently use?

…………………………………………….

…………………………………………….

…………………………………………….

• What challenges do you facing practicing the existing fall prevention measures within the facility?

…………………………………………………………………………………………………………………………………………..

• What do you think should be done to prevent and reduce falls among Alzheimer’s patients within the facility?
• …………………………………………………………………………………………………………………………………….
• …………………………………………………………………………………………………………………………………….
• …………………………………………………………………………………………………………………………………….

Survey II

1. Do you think you are at risk of fall?

1. Why……………………………………………………………………………………………………………………………..

…………………………………………………………………………………………………………………………………….

• What measures are set in place to protect yourself from falling?

1. Explain…………………………………………………………………………………………………………………………..

………………………………………………………………………………………………………………………………………

• How can you prevent yourself from falling?

………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………