Research Question
The approach of evidence based nursing (EBN) is aimed at making quality decisions related to health care and providing care that is based upon the clinical expertise gained personally in combination with the most current, relevant research available on the chosen topic. EBN is a process founded on the collection, interpretation along with appraisal and integration of valid, clinically significant as well as applicable research (El-Khoury et al., 2013). This aims to discuss an area of evidence based nursing through the formation of clinical questions using the PICOT framework. Additionally systematic review of literature is conducted in order to discuss the area of practise.
In order to develop the research question, the PICO (T) framework will be used as this format makes it easier to identify a clinical research problem. This helps to formulate the search strategy through the identification of the key concepts which are required to be a part of the article that can answer the question (Cadore et al., 2013). The PICO (T) stands for:
P – Population = who is your population
I – Intervention = what is your intervention
C- Comparator – what is your comparator
O – Outcome = what is your outcome
T- Time
The PICO question is as follows:
“Does fall preventive intervention like exercise programs prevent fall prevention in older adults in the palliative care units suffering from chronic back pain?”
P – Older adults in the palliative care units with back pain
I –Fall preventive intervention like exercise programs
C- Medications
O – Fall prevention in chronic back pain
PICOT questions:
Intervention- In older adults with back pain, how do regular exercises compared to medications affect the risk of fall?
Therapy- In older adults suffering from back pain, what is the effect of regular exercises compared to medications on the prevention of falls?
Prognosis- In older adults suffering from back pain, how do regular exercises compared to medications influence the risk of fall?
Diagnosis- In older adults suffering from back pain, how do regular exercises compared with medications more accurate in diagnosing fall in patients?
Etiology- Are older adults suffering from back pain who have regular exercises compared with those without medications at the risk of falls?
Meaning- How do older adults suffering from back pain with regular exercises perceive the risk of falls?
The primary research article selected for this study is based on the research question selected that is based on the palliative care. With development of chronic back pain, most of the older adults fail result in decrease of balance and strength. Due to this there is an increase in the fall related risk factors. Therefore this study aims to assess the impact of fall prevention programs on well-being and the self-efficacy of the older adults in terms of fall. This primary study implements the random control trial (RCT), therefore a quantitative approach was used for research. The sample size included 54 participants who belonged to the age group of 65 to 80. The testing protocol comprises tests for the assessment of the following: static / dynamic steady-state balance, proactive balance along with strength, and power (Karlsson et al., 2013). The individuals who participated in the trial were randomly allocated to the intervention group as well as the control group. Data was collected through the conduction interviews as the post-tests after the intervention. Data was analysed through statistical analysis by priori power analysis, of the obtained data. The findings of the study reveal that the combination of balance and strength / power training was successful in improving performance in variables of the risk of fall of older adults in a supervised condition. Training and exercises under supervision helped the older population to retain quality of life and it also helped to lower the cost of medical care system (Cadore et al., 2013).
Evaluation of research
The research topic selected here deals with the risk of falls in older patients in the palliative care unit especially in case of those who are suffering from chronic health conditions such as back pain. Falls is often seen to be the leading cause of injury and death among older adults. The older individuals have a tendency to be more prone towards fall injuries as they have higher prevalence of delayed recovery functions and psychological changes due to the related issues. In addition to this, most of the older adults who experience fall develop a fear of falling, and up to 40% of these individuals therefore restrict their day to day activities of living. This in turn has a significant impact on the decline in physical fitness, depression and social isolation (Carande-Kulis et al., 2015).
In accordance to the National Strategic Framework for Chronic Diseases, the objectives state that every Australians has the right to receive effective, appropriate and efficient quality health care. People suffering from chronic conditions often have multi-morbidities, the levels of which vary in terms of complexity. They also require increased and ongoing access to a range of services and self-management support (Ungar et al., 2013). Therefore the selected clinical research area will be appropriate in providing care to this concerned population of individuals as the preventive programs like exercises help in managing the quality of life, thus supporting the patients during poor health. In regards to the framework, the preventive measures of fall actively engaging people in their own health care along with their carers and family members, thus empowering the patients to control their own heath conditions.
The existing literature related to the discussed clinical research area provides evidences as to the beneficial effects of the preventive measures in order to reduce the risks of fall in palliative care. Pfortmueller, Lindner & Exadaktylos, (2014) in a study stated that the older adults are more prone to injury due to fall because of the higher rates of prevalence of comorbidities along with the other factors like changes in physiology due to age, associated with delayed functional recovery. This in turn results in further de-conditioning and elevated incidences of falls. Detection of the risk factors related to fall is quite important as there is a need to implement preventive strategies that are effective in nature as well as specifically tailored for fall prevention. Several studies had mentioned that the most common intrinsic factors that are associated with falls involves muscle weakness associated with deficits in balance along with gait instabilities. The studies also reveal that these intrinsic risk factors might be modified through the implementation of exercisesin a structured and planned way. Additionally the repetitive physical activities in community-based organized exercise programs often play a significant role in fall prevention. A study by Miake-Lye et al., (2013), showed that conduction of fall risk assessment protocols on a regular basis is able to assist in identification of individuals who are at risk to make recommendations and additionally help optimize the strategies of prevention. Granacher et al., (2013) argued that on the basis of a thorough fall-risk assessment, development of specifically tailored balance and resistance training programs can be initiated which are essential for the improvement of the deficits like in muscle strength and power along with balance performance. In order to attain fall prevention, the exercises ate able to promote static or dynamic steady-state along with proactive and reactive balance should be trained complementarily. According to Williams, Szekendi & Thomas, (2014), many fall prevention interventions have proven to be beneficial inn terms of exercise on the intrinsic fall risk factors. In spite of the presence of substantial evidence, the programs have not been sufficiently implemented into clinical practice. With the aim of reducing the burden of falls in the older population, the fall prevention programs that are easy to administer are required to be developed as well as implemented on a global basis. However there are still lack of skilled people because of which there is inadequate communication between researchers and the policy makers or the clinicians. The barriers of the health system include inadequate financial resources which in turn hinder the implementation of current evidences of research into the practice. Although sometimes there is lack of evidence regarding the fact that how the fall prevention can be included in the services of the community, there is hardly any data available regarding dose–response relationships for optimal exercise for fall prevention (El-Khoury et al., 2013). A study concluded that various methods as well as programmes for the prevention such injuries exist, which includes exercise on a daily basis along with vitamin D and calcium supplementation. Additionally there might be withdrawal of psychotropic medication as well as from cataract surgery or like the professional environment hazard assessment and modification, hip protectors. It might also involve the multifactorial preventive programmes for simultaneous assessment and reduction of many of the predisposing and situational risk factors (Karlsson et al., 2013).
Research Topic
The present study discussed only the qualitative approach of the study therefore all the factors that contribute to the risk of the fall were not addressed in details. Therefore in order to get a better insight of this clinical research area, a quantitative approach might be useful for further research so that a literature review through the implementation of systematic review might be conducted. Suggestions might also be provided in terms of the fact that the sample size was quite small which was considered. Additionally the research that was conducted in the selected primary study was not applicable to all scenarios but was only specific for the palliative care units. This cannot be projected on the situations of the older adults who are residents of the care homes. Therefore further research is required is required in order to determine that whether the considered fall prevention intervention discussed in the research question is applicable for the older patients residing in the care homes.
Conclusion
In conclusion it can be stated that the process of prevention of fall is a multifaceted endeavour. This originates from the various reasons of fall, and the various factors that contribute to the risk factors along with the fragility and the reduced responsiveness through the interventions of many older people. There is also a double-edged effect obtained from various intervention strategies that might increase on of the risks of fall while another one gets reduced. The interaction existing between the falls, the levels of activity, fragility associated with injury needs to be explored more carefully.
El-Khoury, F., Cassou, B., Charles, M. A., & Dargent-Molina, P. (2013). The effect of fall prevention exercise programmes on fall induced injuries in community dwelling older adults: systematic review and meta-analysis of randomised controlled trials. BMj, 347, f6234.
This article aims to determine whether the fall prevention exercise interventions are useful for the older community dwelling people and to what extend is it helpful in preventing the different types of fall related injuries
Randomised controlled trials was implemented for determination fall prevention exercise interventions, which targeted older (>60 years) community dwelling people. It provided quantitative data on injurious falls, serious falls, or fall related fractures.
Exercise programmes that were designed in order to prevent falls in older adults there was tendency of prevalence of injuries caused by falls, including the most severe ones. Such programmes also reduce the rate of falls leading to medical care.
Literature Review
Hoffmann, T. C., Maher, C. G., Briffa, T., Sherrington, C., Bennell, K., Alison, J., … & Glasziou, P. P. (2016). Prescribing exercise interventions for patients with chronic conditions. Canadian Medical Association Journal, 188(7), 510-518.
The aim of this article is to determine the beneficial effect of exercise in the chronic conditions.
The article showed that the various type of exercise like yoga v. graded activity seems less important than the quality of implementation supervision, inclusion of a home program and duration of the program have been shown to improve treatment effect. These programs are able to address the psychological characteristics, such as catastrophizing, pain self-efficacy and fear of injury/movement that can be barriers to engaging in physical activity which are explicit in nature.
Stubbs, B., Binnekade, T., Eggermont, L., Sepehry, A. A., Patchay, S., & Schofield, P. (2014). Pain and the risk for falls in community-dwelling older adults: systematic review and meta-analysis. Archives of physical medicine and rehabilitation, 95(1), 175-187.
The aim of this article is to conduct a systematic review and meta-analysis in order to establish the association that exists between chronic pain and falls in community-dwelling older adults.
Searches were conducted independently using a methodological assessment. Studies which were included focussed on the fact that the adults were 60 or above in age, who were seen to have experienced falls over 6 or more months; and identified a group with and without pain.
Cadore, E. L., Rodríguez-Mañas, L., Sinclair, A., & Izquierdo, M. (2013). Effects of different exercise interventions on risk of falls, gait ability, and balance in physically frail older adults: a systematic review. Rejuvenation research, 16(2), 105-114.
Carande-Kulis, V., Stevens, J. A., Florence, C. S., Beattie, B. L., & Arias, I. (2015). A cost–benefit analysis of three older adult fall prevention interventions. Journal of safety research, 52, 65-70.
Carande-Kulis, V., Stevens, J. A., Florence, C. S., Beattie, B. L., & Arias, I. (2015). A cost–benefit analysis of three older adult fall prevention interventions. Journal of safety research, 52, 65-70.
El-Khoury, F., Cassou, B., Charles, M. A., & Dargent-Molina, P. (2013). The effect of fall prevention exercise programmes on fall induced injuries in community dwelling older adults: systematic review and meta-analysis of randomised controlled trials. BMj, 347, f6234.
El-Khoury, F., Cassou, B., Charles, M. A., & Dargent-Molina, P. (2013). The effect of fall prevention exercise programmes on fall induced injuries in community dwelling older adults: systematic review and meta-analysis of randomised controlled trials. BMj, 347, f6234.
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.
Hoffmann, T. C., Maher, C. G., Briffa, T., Sherrington, C., Bennell, K., Alison, J., … & Glasziou, P. P. (2016). Prescribing exercise interventions for patients with chronic conditions. Canadian Medical Association Journal, 188(7), 510-518.
Karlsson, M. K., Magnusson, H., von Schewelov, T., & Rosengren, B. E. (2013). Prevention of falls in the elderly—a review. Osteoporosis International, 24(3), 747-762.
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.
Pfortmueller, C. A., Lindner, G., & Exadaktylos, A. K. (2014). Reducing fall risk in the elderly: risk factors and fall prevention, a systematic review. Minerva Med, 105(4), 275-81.
Stubbs, B., Binnekade, T., Eggermont, L., Sepehry, A. A., Patchay, S., & Schofield, P. (2014). Pain and the risk for falls in community-dwelling older adults: systematic review and meta-analysis. Archives of physical medicine and rehabilitation, 95(1), 175-187.
Ungar, A., Rafanelli, M., Iacomelli, I., Brunetti, M. A., Ceccofiglio, A., Tesi, F., & Marchionni, N. (2013). Fall prevention in the elderly. Clinical Cases in mineral and bone metabolism, 10(2), 91.
Williams, T., Szekendi, M., & Thomas, S. (2014). An analysis of patient falls and fall prevention programs across academic medical centers. Journal of nursing care quality, 29(1), 19-29.
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