Clinical Governance and Practice Improvement

This paper critically analyses the fall prevention strategies in hospital inpatients and how it is relevant to clinical governance. It includes a systematic review, a randomised control trial and a qualitative study to examine the perception of nurses about the use of evidence-based fall prevention interventions. The paper provides useful evidence about various fall prevention strategies.

Running head: CLINICAL GOVERNANCE AND PRACTICE IMPROVEMENT
CLINICAL GOVERNANCE AND PRACTICE IMPROVEMENT
Name of the Student
Name of the University
Author Note

1CLINICAL GOVERNANCE AND PRACTICE IMPROVEMENT
Introduction
Clinical governance is a process through which the health care organisations make
continuous improvement strategies for improving the quality of their services and upholding
high standards of care to the patients (Van Zwanenberg & Edwards, 2018). There are some
key performance indicators that determine the presence of clinical governance in a health
care organisation, among which fall prevention is an important one.
Falls are a public health problem word wide. Hospitalisation increases the risks of
falls. Fall is clinical settings might be due to illness, medications, gait impairment and
unfamiliar environment. Fall may lead to fractures, haemorrhages, prolonged hospital stay,
increased mortality and moreover reducing the reputation of the clinical setting. Fall is
mainly caused in the older adults and decreases their quality of living (Deandrea et al., 2013).
Till now many strategies have been taken to prevent falls in the hospital inpatients upholding
the clinical governance and reputation of the setting. Clinical government arrangements
involve development of the evidence based fall prevention tools, policy of the trust and
guidelines and extensive staff training programs. Notably, fall among the inpatients can be
reduced by the seven pillars of clinical governance- Service user, carer and public
involvement, Risk management, Clinical audit, Staffing and staff management, Education
and training, Clinical effectiveness and Clinical information (Azami-Aghdash et al., 2013).
Hence, fall prevention is highly relevant to clinical governance within a hospital setting. This
paper would critically analyse the fall prevention strategies.
Critiquing the literature
Three papers have been critically appraised using the CASP tool. CASP tools for
qualitative research, quantitative research and systematic review has been used in analysing

2CLINICAL GOVERNANCE AND PRACTICE IMPROVEMENT
each of the three papers. The CASP tool helps to find and make sense of the research
evidences (Nadelson & Nadelson, 2014).
Higher rate of falls are identified in the geriatrics, neurology and the rehabilitation
wards. Fall among the impatient occur due to a large number of predisposing factors such as
the age, mobility, impairment,certain medications, poor lighting, uneven flooring or the
shortage of staff . Miake-Lye et al., (2013), have written a systematic review to assess the
harms and the benefits of the multicomponent inpatient programs to prevent falls and to
assess the factors associated to the successful intervention of the programs. Twenty studies
have been chosen from the database. The papers chosen for the review was appropriate. Two
large randomised control trails were included in the study. All the articles have been searched
by the databases such as PubMed, CINAHL and the Web of science. All the studies included
were in English. The rigor of the studies chosen were not analysed. The intervention
components of the fall prevention program that were studied are patient education, the bed
sign risk sign, staff education, alert wristband, footwear, review after the fall, toileting
schedules, review of the medicines, environmental modifications, bedrail review, the
movement alarm ,the hip protectors, vest belt and cuff restraints.
Study findings
It has been found in the systematic review, that a regular fall risk assessment,
signage of the high risk patients, patient education and manual documentation in the records
of the patients have been associated with reduced fall among the hospital inpatients. In almost
all the papers multicomponent in facility programs have been found to have caused a
statistically significant reduction of falls among the hospital inpatients. The result of the study
was also found to be consistent with the previous reviews on the inpatient fall program. The
significance of the result is that the population group chosen for the systematic review

3CLINICAL GOVERNANCE AND PRACTICE IMPROVEMENT
matches with the actual population facing the issue; the elderly people. Most of the papers
chosen in the review did not report any harm regarding the implementation of the harm
reduction program. None of the papers could found any economic evaluation of the fall
prevention programs. This paper included the papers that described about the role of the
patient infrastructure and the patient safety and culture. One of the limitations of the research
is that the systematic review is limited by the quantity and the quality of the research.
Falls by the elderly people in the nursing care facilities are common events that can
cause loss of independence, injuries or deaths.
Critique
Proper exercise regimen can be helpful in increasing the muscle strength and gait
among the elderly people (Granacher et al., 2013). In relation to this, Gschwind et al. (2013),
have conducted a randomised control trial for assessing the effectiveness of the fall
prevention program, that was developed by an interdisciplinary panel of expert, on body,
power, consumption, cognition and the psychological wellbeing and the fall self –efficacy
among the healthy older adults. In this trial 65- 80 years of age old people were included. The
instruments that were used to assess the self-efficacy are the assessment of the static/
dynamic steady state balance, proactive balance, reactive balance, and strength and power
test. Furthermore the composition of the body will be analysed by using the bioelectrical
impedance analysis system. Psychosocial, cognitive and the fall risk determinants. All the
participants have been randomised in to two intervention groups. The method of the
randomisation was not described. The staffs and the study personnel were not blind to the
study group. One of the groups completed an extensive supervised training program and the
other group completed short term home based activities directed by telephonic instructions.

4CLINICAL GOVERNANCE AND PRACTICE IMPROVEMENT
The trials presented a safe and an active approach for the fall prevention among the older
adults. The interventions used in this study were clearly defined.
Findings
The trials displayed increased psychological and physical wellbeing among the
interventions groups in comparison to ones who were practicing home based activities.One of
the limitation of this study is the low sample size and the fact that the control participants
might not exercise as per the telephonic instructions and the absence of a control group. One
of the strength of this study is that interventions compared to the early fall prevention strategy
is that on the basis of the finding, exercise training programs can be taken up in the
institutions. Furthermore the study also evaluates how minimum home based exercises can
stimulate the physical performance adaptations.
A qualitative study by Wilson et al., (2016), was conducted to examine the perception
of the nurses about the use of the evidence-based fall prevention interventions for mitigating
the fall risk on the patients. The aim of the research is relevant.
As per the findings five major themes have been revealed- the before study fall
prevention strategies, the use of the fall prevention interventions, the beneficial
implementation strategies, the overall impact on the approach to the fall prevention and the
challenges. Thirty four staff nurses were included in the study (Wilson et al., 2016). Five
focus group with an average of the four to five nurses in each of the group was included. A
session lasted for about 60-90 minutes. The recruitment strategy was appropriate to the aim
of the research.
A semi-structured interview was conducted. The qualitative research method for this
paper is appropriate and is worth continuing and provides a detailed idea about the how the

5CLINICAL GOVERNANCE AND PRACTICE IMPROVEMENT
data has been collected. The interview questions were well defined and relevant to the study.
Ethical consideration of the study has been made as each of the participants were contacted
via email and a consent form was being signed. Privacy and confidentiality was maintained
during the data storage. Proper data collection instruments have been used in the study such
as two-digital audio recorders.
The collected data were analysed by a constant comparative study. A thematic
analysis has been used. Major and the minor themes were being identified by two
independent researchers. The rigor of the studies has been maintained by the cross checking
of the transcripts.
As per the findings , most of the nurses have reported that before the study most of the
importance was given only on the generalised fall prevention strategies, but evidence based
practice goes beyond the generalised fall prevention interventions. However, the study had
rightfully identified some of the limitations. The nurse did not discuss about mental status,
increased risk of injury, hence fall prevention perceptions of the nurses in the other categories
were not known. Furthermore, the sample size was also small to be appropriate for the
generalised population. However, the strengths of the study is that this study increased the
mindfulness of the fall and collaboration between the interdisciplinary team members.
Hence in conclusion it can be said that fall prevention among the hospital inpatients
can be prevented by prevention programs such as the proper physical activities to improve the
gait among the fall prone people, vitamin D supplementation for increasing the muscle
strength has been found to be useful. Furthermore, other options such as environmental
assistive technology, staff training and medication review has been found to be useful in
preventing falls. Although there are several limitation of the three papers, but the papers
definitely provide useful evidence about the various fall prevention strategies.

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References
Azami-Aghdash, S., Tabrizi, J. S., Sadeghi-Bazargani, H., Hajebrahimi, S., & Naghavi-
Behzad, M. (2015). Developing performance indicators for clinical governance in
dimensions of risk management and clinical effectiveness. International Journal for
Quality in Health Care, 27(2), 110-116.
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.
Gschwind, Y. J., Kressig, R. W., Lacroix, A., Muehlbauer, T., Pfenninger, B., & Granacher,
U. (2013). A best practice fall prevention exercise program to improve balance,
strength/power, and psychosocial health in older adults: study protocol for a
randomized controlled trial. BMC geriatrics, 13(1), 105
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.
Nadelson, S., & Nadelson, L. S. (2014). Evidence‐based practice article reviews using CASP
tools: a method for teaching EBP. Worldviews on Evidence‐Based Nursing, 11(5),
344-346.
Wilson, D. S., Montie, M., Conlon, P., Reynolds, M., Ripley, R., & Titler, M. G. (2016).
Nurses’ perceptions of implementing fall prevention interventions to mitigate patient-
specific fall risk factors. Western journal of nursing research, 38(8), 1012-1034.

Running head: CLINICAL GOVERNANCE AND PRACTICE IMPROVEMENT
Appendix
Author/s
(year)
Country
Aims
or
Purpose
Sample/ setting
or
Key stake-
holders and
their roles
Design/ methods
or
Type of paper
Main findings
or
Primary argument
Strengths and
limitations of the
paper
Article 1 Miake-Lye
et al.,(2013)
Australia
To assess the benefits and
harms of the
multicomponent fall
prevention program and
the factors related to the
success of the
21 papers were
taken, including
4 meta-analysis
and 2 new large
randomize
Systematic review.
They were
collected using
PubMed from 2005
to 2012.
Findings show that
multiple interventions like
leadership support,
engagement of front-line
staff in program design,
guidance of the prevention
Limitations- Restricted
quality and quantity of
the research, no
exhaustive update of
the reviews.

1CLINICAL GOVERNANCE AND PRACTICE IMPROVEMENT
implementation. controlled trial program by a
multidisciplinary
committee, pilot-testing
interventions, use of
information technology
systems to provide data
about falls, staff education
and training, and reduces
fall prevention
Strengths- large RCTs
were studies,
increasing the
credibility, the
implementation themes
assessment were novel.
Article 2 (Wilson et
al., 2016).
To examine the perception
of the nurses about the use
of the EBP interventions in
preventing the patient-
specific falls.
Thirty-four staff
nurses from the
13 medical
surgical study
units were
included.
Qualitative
research
As per the findings, the
nurses have discussed that
the fall prevention
strategies that are used
normally are not patient
specific and are not much
Strength of the paper is
that the qualitative
study augmented the
mindfulness about falls
and knowledge of EBP
had increased the

2CLINICAL GOVERNANCE AND PRACTICE IMPROVEMENT
effective. They have
admitted that using
Evidence –based research
can be helpful in mitigating
the fall risks.
further implementation
of the strategies.
The limitations are the
small sample size and
that the nurses did not
discuss about the
parameters like mental
status, risk of injury
and previous falls.
Article 3 Gschwind et
al., (2013)
To assess the effectiveness
of a fall prevention
program on the body,
power, consumption,
cognition, the
psychological wellbeing,
and the fall self –efficacy
Healthy old
people (n = 54)
between the age
of 65 to 80 years
participated in
this trial
Randomized
control trial
The trials displayed
increased psychological
and physical wellbeing
among the interventions
groups in comparison to
ones who were practicing
Strength- The trial
provided insight to the
fall prevention exercise
implementation in both
the community and the
home.

3CLINICAL GOVERNANCE AND PRACTICE IMPROVEMENT
among the healthy older
adults.
home based activities. Limitation- Small
sample size and
absence of a control
group

Running head: CLINICAL GOVERNANCE AND PRACTICE IMPROVEMENT