NURS2006 Assignment 3: Clinical Practice Improvement Project Report

This report aims to reduce the rate of fall related injuries among the community dwelling older adults by preparing a thorough exercise regimen. It discusses the relevance of clinical governance, proposed interventions, key stakeholders, CPI tool, barriers to implementation and evaluation of the project.

NURS2006 ASSIGNMENT 3
Clinical Practice Improvement Project Report
Student Name, FAN and ID:
Type your assignment into the white spaces in the template and the rows will
expand as much as you need them to.ie Alex Smith smit0000 ID 1234567
Project Title:
Effectiveness of exercises to reduce fall rates among the community dwelling adult population
Project Aim:
To reduce the rate of fall related injuries among the community dwelling older adults by preparing a
thorough exercise regimen. This project would focus on reducing the falls up to 20% in the ward of X
clinical settings.
In order to reduce the rate of falls an exercise program has to taken up in the X clinical setting. The
patients will be imparted with education regarding the usefulness of the exercise and each patient
will be entrusted with specific exercises by the physiotherapists. The outcome will be evaluated by a
follow up of six months.
Falls and fall related injuries in adults are mainly caused due to the age, poor physical condition, and
lower functional status (Desure et al. 2013). Fall related injuries in elderly person decreases their
quality of life by lessening their confidence. Often older adults feel that in most of the cases, the
cause of the falls can be avoidable. According to Cadore et al.(2013), proper exercise regimens have
been found to decrease falls among the elderly people. Hence this paper aims to focus that exercises
can help to retain balance among the older adults.
Relevance of Clinical Governance to your project
Clinical Governance is the systematic approach to provide the quality of care to the client by
reducing the risks and complication. Clinical risk management involves improvement in the quality
and the safety of health (Heyrani et al.2012). This can be accomplished by detecting the
circumstances that put the patients at risk and then acting accordingly to mitigate that harm. In this
project the risk has been identified as fall among the elderly patients due to lack of balance,
cognitive disability and medication effect (Khoury et al.2013). The strategy in this case is effective
exercise. The staffs are responsible for their own actions and ensure client safety at highest level

(Granacher et al.2013). In this project an attempt has been made to reduce the fall rate in the
community. Therefore, the third pillar of clinical governance, which is risk management, is used to
analyse the risk factor and implement effective intervention to overcome the situation. The incident
of fall has been increasing due to diminish physical functioning and physical inactivity (Iwamoto et
al.2009). As exercise is the most effective way to improve the body balance and prevent falls in
elders in the community. (MS Kaminska et al 2015, p.3407).Exercise is a part of health care and it
gives an opportunity to have social interaction.(Shier.V et al.2016,p.3) . It has been found that
exercises that challenge balancing are far more effective in preventing falls, than those that do not
challenge the balancing program. It has been found that the older adults should practice how to
control the movements of their body's centre of mass (Heyrani et al. 2012). It is always not about fall
related injuries, proper balancing exercises can reduce the risk of some cardiovascular diseases and
many chronic diseases (Gillespie et al.2013). The ACHM and the (American heart association) AHA
recommends regular exercises for the adults aged 65 years and over. According to recent cochrane
review, risks and all rates can be decreased by 15% to 32% depending on the type of targeted
exercise (Horne et al.2013).
Evidence that the issue / problem is worth solving:
Source: (Gillespie et al.2012)
The following graph depicts that fall related deaths occurs among the older adults above the age of
65. Extensive search through literature have found that even a little bit of exercise can help in
prevention of falls among the older adults (Giné-Garriga et al. 2014). According to the
epidemiogical statistics about 30% of community dwelling elders over 65 aged and 50 % over 80
year, fall annually. Fall is the sing cause if disability and mortality. The admission rate of fall related
injuries in Australia were over 60 in Australia as 2,000,000 non fatal injuries are treated in hospitals

in 2013 (Hempel et al. 2013).The cost burden is increasing on health care sector. (Kaminska.MS et al,
2015, p.3407). According to Gillespie et al. (2012), fitness aerobic exercises, balance exercises can be
useful for the elderly people. After the age of 40 the strengths of the lower limb muscle decreases,
which has been considered as one of the driving factors for falls (Granacher et al.2014). Hence,
power exercises, balancing exercises, toe stands, knee curls. Leg extension exercises can be useful
for making the thigh muscles, leg muscles and lower back muscles stronger (Desure et al. 2013). All
these evidences prove that an exercise program is strongly needed in the X- hospital to reduce the
rate of falls and the decrease the chance of sentinel events due to falls.
Key Stakeholders:
The stake holders that play an important part of this project are the patients, the doctors, the nurses
and the physiotherapists.
Physiotherapists- They will review and device the treatment program by using manual therapies and
therapeutic exercises. They are the one to assign particular exercises to specific patients (Moyer
2012).
Patients- They will be giving the feedbacks regarding the interventions.
Nurses- Play the leading role in carrying out the interventions related to falls. A nurse should be able
to use the standard assessment tools for detecting the level of risks apart from the exercises; Some
of the common preventive measures that can be taken by the nurses are hourly rounds,
communication with the patient and medication review (Milisen et al.2012).
Doctors- The doctors will monitor if there is any adverse effect during or after the completion of the
exercise regimen.
CPI Tool:
Clinical practice Improvement is the means of improving and managing the quality of care provided
to the patient. It helps to evaluate the measure that has been taken to ensure a safe and quality care
(Taylor et al.2013). The CPI method is mainly dependent upon the following questions such as ' What
are we trying to accomplish?', How will one know that the setting requires a change?', 'what changes
has to be made that will bring about an improvement in the given problems?'. It is necessary to have
CPI training for learning the skills of comprehensive identifying, planning and identifying the issue.
There are is a couple of CPI tools among which the PDSA model (Plan- Do- Study- Act) are normally

used in the quality improvement strategies aimed at bringing out positive changes in a health care
setting. This model follows a cyclical pattern of impacting and assessing the changes (Taylor et
al.2013). The PDSA cycle is normally used to evaluate changes in the system by designing a plan, and
then carrying out the plan followed by the subsequent understanding and follow up of the plan
(Terroso et al.2013). It is necessary to answer 3 questions before using the PDSA cycle in this
project, The goal of this project, evaluation of the reached goals, interventions for reaching the
goals.
The goal of this project is to reduce the rate of falls among the older adults in the X hospital ward.
There will exercise programs for the elderly patients of the ward under the supervision of the
doctors, physiotherapists and the nurses (winter et al.2013). The outcome of the implemented plan
have been assessed and studied. A record plan is kept to jot down the names of the respondents
who have participated in the drills and the exercises (Gillespie et al.2013). Finally a feedback is taken
from both the parties receiving the benefits that are the patients and the parties giving the benefits
such as the physiotherapist and the nurses. All the records and the documentations of the feedback
were evaluated for implementing routine exercise plan for the fall prone persons in the hospital
ward.
PDSA tool
Tool: Patients feedback
Step: Exercise program for the elderly patients in the hospital ward, for preventing falls.

Cycle- 1st try
Plan: To give a proposal to the finance department and Director of health care sectors and
community welfare organisation, requesting funds for project budget.
Steps: To introduce exercise in the X health care setting.
Do- There will be exercise programs regularly for about 30 minutes under the supervision of the
therapists.
Study- The doctors and the physiotherapists will measure the outcomes. The nurses will record
how well the intervention worked.
Act- The effectiveness and outcome of the exercise should be mentioned in record sheet and
should be kept for the development of further improvement of the strategies.
Summary of proposed interventions:
One of the proposed interventions to prevent falls and fall related injuries in older adults is by
carrying out physical exercises regularly. More or less all falls are related to lack of physical fitness.
The PDSA tool used above can be elaborated as follows:-
PDSA tool
Tool: Patients feedback
Step: Exercise program for the elderly patients in the hospital ward, for preventing falls.
Cycle- 1st try
Plan: -In the planning phase-a proposal will be written to the finance department and Director of
health care sectors and community welfare organisation, requesting funds for project budget. The
copy will be sent in 4 December 2015.
A meeting will be held for discussing the topic with the community welfare agency or organisation to
approve the project. We plan to put up an exercise program in the ward of the X hospital. We also
plan to record the outcomes for implementing positive changes in the hospital settings.
Do- The exercises programme will be held in the X class settings and will be conducted under
supervision.
 The primary care instructor may help in recruitment and promote adherence to the exercise
regimen.
 The adherence can be promoted by phone calls, regular session and home visits.

 The nurse might assist clients in exercise and seek advice from physician.
 The physiotherapist is the instructor, will prescribe exercise individually during 5 visits over
six month. The family members can also take part in this group to support their elders.
 The exercise will be held for 30 minutes, three times per week. The programme include
muscle stretching, walking and balance retraining .The client aged between 65 -75 will be
invited by primary care worker to participate. The arising health issues by exercises will be
handling by Physiotherapist and nurse.
Study- It is necessary to study whether the exercise plans worked well or not, whether the exercises
have to be continued or stopped. The doctor will monitor the outcomes of each participants of the
exercise regimen on the basis of prescribed exercise. If there are any adverse effects, then the
doctor will try to mitigate that effect. The nurses will document the feedback from each patient for
further evaluation. It will help in keeping a record of the patients who did not take part in the
program.
Act- A record sheet be kept that shows name of the participants, who have attended the
programme. It will also include the exercise performance and timing of exercise held. The
effectiveness and outcome of the exercise should be mentioned in record sheet. It is necessary that
the patients be approached often, reminding about their exercises as, once a patient steps out of a
building, and he would likely not follow the rules.
Barriers to implementation and sustaining change:
Studies have shown that the reason of non adherence to exercise programme are as follows:-
 Elderly persons tend to forget easily-They are likely to forget the rules and the norms as
soon as they get away from any clinical setting. In a clinical setting, they remain under the
continuous surveillance of the doctors and the nurses and everything has to be done in time
as, a continuous documentation followed, so normally omissions does not occur
(Loganathan et al. 2015).
 The cost of transport to reach in programme- In many cases, the elderly persons have to
financially depend on their children. In some cases an elderly person might not get that
much support from their family, such that they cannot afford the costs of reaching the
program venue.

 The attitude and judgement of elders- Elderly people are often judgemental and are often
against any new changes, be it a positive change or a negative ones. Hence it sometimes
becomes very difficult to convince them or make them understand the beneficial effect s of
a particular thing (Milisen et al. 2013).
 Very frail elderly are worried to participate- some patients who are very frail and week
cannot be brought under any exercise schedule. They and the patient are often worried to
participate in this sort of exercise programs as they might think that this could deteriorate
their health status (Loganathan et al. 2015). A study should not be preceded without the
consent of the patients and his family hence it is advisable not to include the unwilling
patients.
 Improper conduct of the health care professionals and the clinical staffs- It is not that all
clinical staffs and the therapists have to be excellent in their codes of conduct. A nurse or a
clinical staffs might not deliver proper education to the patient or may not help the older
patients in carrying out necessary exercise.
Evaluation of the project:
A conclusion can only be made after the feedback from the patients. Positive outcomes would help
to continue the exercise programs and the negative outcomes will be evaluated for further
improvement. A pre and a post study of the intervention should be useful in evaluating the success
of the project.
For the evaluation, the past 6 months data has to be collected. Feedback sheets can be provide to
the patients containing a list of questionnaire such as :-
 Why do you think exercise is necessary to prevent falls?
 Did you notice any desirable changes after exercise programs?
 Has there been any improvement?
 Did the staffs explain all the good and the bad points of an exercise before the
commencement of the exercise regimen?
 Were the education and the training helpful to you?

 Were the clinical staffs cooperative?
 Did they remind you of your exercise in the past six months?
Feedback can also be taken from the doctors, who will assess the patients after the exercise
program, regarding their improvement in health. The feed backs can then be recorded and analysed
qualitatively. Based on these feed backs future plans will be constructed.

References
Cadore, E.L., Rodríguez-Mañas, L., Sinclair, A. and 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), pp.105-114.
DeSure, A.R., Peterson, K., Gianan, F.V. and Pang, L., 2013. An exercise program to prevent
falls in institutionalized elderly with cognitive deficits: a crossover pilot study. Hawai'i
Journal of Medicine & Public Health, 72(11), p.391.
El-Khoury, F, Cassou, B, Charles, M & 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 : British Medical Journal
(Online), vol. 347,pp.1-13.
Gillespie, L.D., Robertson, M.C., Gillespie, W.J., Sherrington, C., Gates, S., Clemson, L.M. and
Lamb, S.E., 2012. Interventions for preventing falls in older people living in the
community. The Cochrane Library.
Giné-Garriga, M., Roqué-Fíguls, M., Coll-Planas, L., Sitjà-Rabert, M. and Salvà, A., 2014.
Physical exercise interventions for improving performance-based measures of physical
function in community-dwelling, frail older adults: a systematic review and meta-
analysis. Archives of physical medicine and rehabilitation, 95(4), pp.753-769.
Granacher, U., Gollhofer, A., Hortobágyi, T., Kressig, R.W. and 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), pp.627-641.
Hempel, S., Newberry, S., Wang, Z., Booth, M., Shanman, R., Johnsen, B., Shier, V., Saliba, D.,
Spector, W.D. and Ganz, D.A., 2013. Hospital fall prevention: a systematic review of
implementation, components, adherence, and effectiveness. Journal of the American
Geriatrics Society, 61(4), pp.483-494.
Heyrani, A., Maleki, M., Marnani, A.B., Ravaghi, H., Sedaghat, M., Jabbari, M., Farsi, D., Khajavi, A.
and Abdi, Z., 2012. Clinical governance implementation in a selected teaching emergency
department: a systems approach. Implementation science, 7(1), p.84.
Horne, M, Skelton, DA, Speed,S & Todd,C 2013, ‘Falls Preventionand the value of exercise:
Saleint beliefs in among South Asian and White British Older Adults’,Clinical Nursing
Research, Vol.23,no.1, pp. 94-110.

Iwamoto, J, Suzuki, H, Tanaka, K, Kumakubo, T, Hirabayashi, H, Miyazaki, Y, Sato, Y, Takeda,
T & Matsumoto, H 2009, "Preventative effect of exercise against falls in the elderly: a
randomized controlled trial", Osteoporosis International, vol. 20, no. 7, pp. 1233-40.
Loganathan, A., Ng, C.J., Tan, M.P. and Low, W.Y., 2015. Barriers faced by healthcare professionals
when managing falls in older people in Kuala Lumpur, Malaysia: a qualitative study. BMJ open, 5(11),
p.e008460.
Milisen, K., Coussement, J., Arnout, H., Vanlerberghe, V., De Paepe, L., Schoevaerdts, D.,
Lambert, M., Van Den Noortgate, N., Delbaere, K., Boonen, S. and Dejaeger, E., 2013.
Feasibility of implementing a practice guideline for fall prevention on geriatric wards: A
multicentre study. International journal of nursing studies, 50(4), pp.495-507.
Moyer, V.A., 2012. Prevention of falls in community-dwelling older adults: US Preventive
Services Task Force recommendation statement. Annals of internal medicine, 157(3),
pp.197-204.
Taylor, M.J., McNicholas, C., Nicolay, C., Darzi, A., Bell, D. and Reed, J.E., 2013. Systematic
review of the application of the plan–do–study–act method to improve quality in
healthcare. BMJ Qual Saf, pp.bmjqs-2013.
Terroso, M., Rosa, N., Marques, A.T. and Simoes, R., 2014. Physical consequences of falls in
the elderly: a literature review from 1995 to 2010. European Review of Aging and Physical
Activity, 11(1), pp.51-59.
Winter, H., Watt, K. and Peel, N.M., 2013. Falls prevention interventions for community-
dwelling older persons with cognitive impairment: a systematic review. International
psychogeriatrics, 25(2), pp.215-227.

NURS2006 Assignment 3 - CPI paper Marking Rubric
PERFORMANCE STANDARD
CATEGORY &
WEIGHTING Excellent Work Good Work Passing Work Unsatisfactory work
Project Aim
and Evidence
the issue is
worth solving
20%
Aim succinct & clearly
defined. All evidence
relevant & rigorous.
Shows a very high level of
insight & relevance to the
issue.
(17-20) 
Aim well defined.
Some irrelevant
information but most
evidence relevant &
rigorous. Shows a very
good level of insight &
relevance to the issue.
(13-16.5) 
Aim stated with some
ambiguity. Some evidence
relevant and rigorous,
Acceptable level of
insight.
Quite a lot of irrelevant
information is present.
May be overlong/ too
brief
(10-12.5) 
Aim not clearly stated
Most evidence is not
relevant or rigorous.
Poor level of insight &
relevance to the issue.
Significant amount of
irrelevant/ missing
information.
(0–9.5) 
Relevance of
Clinical
Governance to
your project
10%
Succinct and highly
relevant discussion of the
relevant pillar of clinical
governance related to the
chosen clinical issue.
(9-10) 
Succinct and mostly
relevant discussion of the
relevant pillar of clinical
governance related to the
chosen clinical issue.
(7-8.5) 
Adequate discussion of
the relevant pillar of
clinical governance
related to the chosen
clinical issue.
Some parts not relevant
Overlong / too brief, may
be missing relevant
information.
(5-6.5) 
Inadequate discussion of
the relevant pillar of
clinical governance
related to the chosen
clinical issue. Overlong /
too brief, may be missing
a significant amount of
relevant information
(0-4.5) 
Key
Stakeholders
5%
Identifies most relevant
key stakeholders.
Discusses clearly how they
could be involved in the
project.
Succinctly and expertly
written. Very high level of
insight into the role of
stakeholders.
(4.5 - 5) 
Identifies some relevant
key stakeholders and
adequately discusses how
they could be involved in
the project.
Very well written. Good
level of insight into the
role of stakeholders.
(3.5-4.25) 
Identifies a few relevant
key stakeholders.
Mentions briefly how they
could be involved. Quite
well written but contains
some irrelevant
information, or minor
information is missing.
Adequate level of insight
into the stakeholder role.
(2.5 – 3.25- ) 
Contains irrelevant
information, or major
information is missing.
Inappropriate or no key
stakeholders are
identified Poor insight
into the stakeholder role.
(0-2) 
Clinical Practice
Improvement
Tool
20%
Describes a relevant CPI
tool Very clearly discusses
how it could be used to
address the aim and
implement the
interventions. Succinctly
and expertly written with
no omissions of relevant
information.
(17-20) 
Describes a relevant CPI
tool Discusses quite
clearly how the tool could
be used to address the
aim and implement the
interventions. Well
written but may contain
some irrelevant
information, or some
minor information is
missing
(13-16.5) 
Describes a relevant CPI
tool and adequately
discusses how the tool
could be used to address
the aim and implement
the interventions.
Not succinct, contains
irrelevant information,
significant information is
missing
(10-12.5) 
A relevant CPI tool is not
identified. There is no
adequate discussion of
how the tool could be
used to meet the aim or
implement the
interventions.
Contains irrelevant
information or some
major information is
missing.
(0–9.5) 
Summary of
proposed
interventions
20%
All relevant interventions
are discussed very well.
Project outline is very
clear and the relevance to
clinical practice is very
high.
Most relevant
interventions discussed
quite well.
Project outline is clear &
relevance to clinical
practice is good. Contains
some irrelevant
information, minor
information may be
Acceptable level of
relevant interventions
discussed.
Project outline mostly
clear, although it may be
unclear how the project
would actually be
implemented in clinical
practice due to
Some elements missing or
incomplete. May contain
large amounts of
irrelevant information.
Project poorly described
and it is unclear what the
project actually entails or
its relevance to clinical
practice.

(17-20) 
missing.
(13-16.5) 
irrelevant/missing info
(10-12.5)  (0–9.5) 
Barriers to
Implementatio
n
15%
Identifies most potential
barriers to
implementation & clinical
change. Discusses in
depth how these barriers
could be overcome or
minimised.
(13-15) 
Identifies some potential
barriers to
implementation & clinical
change. Discusses how
these barriers could be
overcome or minimised.
(10-12.5) 
Identifies a few potential
barriers to
implementation & clinical
change. Discusses how
barriers could be
overcome or minimised.
Minor omissions and/or
some irrelevant
information present
(7.5-9.5) 
Relevant barriers not
identified. Poor or no
discussion about how
they could be overcome
or minimised. Major
omissions, much of the
information provided is
irrelevant / unrelated to
the CPI goal.
(0-7) 
Evaluation of
the project
10%
Succinct discussion of an
excellent and achievable
plan for how the
intervention/s could be
evaluated.
(9-10) 
Succinct discussion of a
very good and mostly
achievable plan for how
the intervention/s could
be evaluated.
(7-8.5) 
Discussion of an adequate
plan for how the
intervention/s could be
evaluated. Some parts not
relevant or achievable
Overlong / too brief, may
be missing relevant
information.
(5-6.5) 
Plan absent or not well
described. Most or all of
the plan is not relevant or
achievable
Overlong / too brief, may
be missing a significant
amount of relevant
information
(0-4.5) 
Name of Marker
Grade
Overall Comments