Critical evaluation of falls prevention education to staff within residential homes: An analytical report. Illustrate your essay with specific examples.

Introduction
Falls and their consequences especially in residential homes are a leading cause of death in elderly population especially people 75 years and older and it represents a major cause of disability in older people, posing a serious threat to their health and well being and about one third to one half of the people aged over 65 fall each year. (National Service Framework(NSF) for Older People, 2001). They place a major burden on the family members, making excessive demands on the health care professionals especially the nursing staff and strain on the resources of institutions (Davis, 1995).
Although hospitals and nursing facilities more or less differ in their goals, distribution and orientation of their staff, populations of individuals cared for and environmental design principles, the factors associated with falls as well as intervention strategies within each institution are almost similar in many respects. It has been reported in some studies that falls seem to be a marker of increasing fragility and risk of dying and that clustering of falls prior to death has been reported in deaths in residents of home for the elderly, in whom those with many falls had a particularly high death rate (Gryfe et al, 1977).The consequences of falls are challenging for the institutions, families and the individuals themselves and increased health care cost. Nursing staff caring for patients and residents with recurrent falls may find the responsibility of constantly deciding between the individual’s desire for autonomy and the families request for safety and protection against the risk of falls emotionally demanding. Sometimes the staff themselves may feel and experience stress, guilt and self doubt about their ability to deliver self care (Rein tideiksaar, 2002).In this essay, more importance will be given to demonstration of skills and knowledge of public health and health promotion in relation to the practice of nurse practitioner within the community based primary care. The public health interventions beneficial to the frail elderly people for health promotion within residential homes will be identified and critically evaluated in this essay using the Ewles and Simnetts (2003) model for planning and evaluating health promotion interventions.
Outline of the chosen health promotion activity
The health promotion activity chosen in this essay will be based on the experience on the knowledge and skills of the nurse practitioner in a community based primary care in identifying the public health interventions that could be beneficial to the frail elderly, within residential homes by using various approaches. These will include selecting the health promotion activity and approach, the area of practice; using the Ewles and Simnett (2003) model for planning and evaluating the health promotion strategy.
Discussion of relevance to the area of practice
One of the most common and critical problems faced by the residential based health care providers including the nursing staff is that of falls among the elderly population. Falls particularly repeated falls are a major cause of physical and psychological trauma and falls that occur repeatedly are more likely to produce a cumulative adverse effect on the individuals capacity for mobility causing periods of immobility and as an outcome of complications and premature death (Rein tideiksaar,2002).Nursing practitioners have got a very important role to play in health promotion and health education about prevention of falls among elderly population in residential homes, where frequent admissions are made based on the homely atmosphere as against the hospital setting.
The community involved in this essay will be the elderly population and patients who are living in residential homes and who are more prone to falls due to various factors and the staff involved in education of these populations regarding the various measures that need to be taken, to avoid the occurrence of falls in them. The problem of increased frequency of falls in residential homes was identified and evaluated when a survey was conducted as part of the health care program for the elderly in old age residential homes. The government policies and strategies formulated by local and national bodies were taken into consideration, while the survey was planned so that the guidelines included in their strategy were made use in planning of this health promotion activity and much priority was given to this health promotion activity after consultation with the concerned health authorities.
Aims and objectives

1. To demonstrate the knowledge and skills of a nurse practitioner in a community based primary care in the application of public health and health promotion practices in relation to their nursing practice.
2. To identify the public health interventions that would be beneficial to the frail elderly, within the residential homes and its practical application.

The objective of this assignment is to critically appraise a health promotion initiative related to nursing practice in relation to the prevention of elderly population in residential homes. Through this health promotion activity, the specialized skills and behavior of community based nurse practitioners in managing elderly people in residential homes could be improved and further new guidelines could be formulated ,which could be very much useful in prevention of falls in them, if the appropriate measures could be taken at the right time. By conducting this study it could be possible to assess the real situation of the role of the nursing practitioner in health promotion and the present public health interventions could be identified and could be verified or modified if needed in future and the merits and demerits of this program could be analyzed for future interventions.
The objectives may be considered as challengeable as it’s impracticable to demonstrate the knowledge and skills of a nurse practitioner especially in public health care setting, due to the heavy work load of the nurses and the variation in their practice settings.Gryfe (1997) reported that the hospitalized and institutionalized elderly are having more risk of falling than the older people living in the community. Fine (1959) in his study reported that falls among the elderly were more common when there was lesser number of nursing staff to look after them. But some other studies have shown that the frequency of falls was also decided by the availability and competence of the nursing staff rather than the staff number (Morse et al, 1987).It has been shown that the staff with a more positive attitude were more inclined to encourage patients to be more independent, thus increasing the risk of falling among them (Harris, 1989).One of the most important duties of the nurse is to identify those who are more prone to frequent falls and the limitation of the risk of falls. Studies have shown that there is an association between the staff numbers and frequency of falls among the elderly living in resident homes. But it could be attainable and could be measured, if the proper guidelines formulated by the local and national health bodies are checked and if the implemented government policies could be verified based on the nursing practice in these residential homes.
Ewles and Simnett (2003) model of health promotion will be used in this phase of the essay and a case example will be used to critically evaluate the various approaches and the preferred approach for health promotion in this case. Studies have shown that the model of health promotion developed by Ewles and Simnett (2003) seems to be less complex and more likely to be used within a general nursing context associated with health promotion.(Whitehead,2001).The following steps are used in the Ewles and Simmett (2003) model when used for the evaluation of health promotion process-steps such as identifying the needs and priorities, setting aims and objectives of health promotion, deciding the best ways of achieving the proposed aims and objectives, identifying the resources, planning the evaluation methods, setting an action plan, implementation of planning including the evaluation which will be followed in this essay.
The Ewles and Simnett (2003) model makes use of mainly five approaches to health promotion which includes the medical approach; educational approach; behaviour change approach; client-centred approach and societal change approach. The various approaches and their relevance are discussed below.
The client-centred approach facilitates health promotion of things that the client feels will be of benefit (Ewles and Simnett, 2003); this could suggest that the approach will be based on the patient’s desire regarding his treatment and his ideas to help in prevention of further falls. Here the patient might be interested to find himself safe from falling and this could be supported by the nursing practitioner or staff in charge by giving him various ideas regarding how to support himself from occurrence of falls in future.
Another approach could be the societal change approach which usually focuses on changing the whole community itself and not just individuals within it (Ewles and Simnett, 2003).Here by implementation of changes at the community level, it could be possible to create awareness among the members of society as a whole regarding the consequences of falls that could occur as a result of it. Here the benefits are more for a community rather than individual benefits. A similar approach is the educational approach to health promotion which helps in giving individuals more specific information and details to explore the health benefits or detriments for themselves. (Ewles and Simnett, 2003).In the educational approach, more importance is given to the teaching provided to the elderly population regarding the various methods, which could be helpful in prevention of falls among them. They could be taught about the various supportive measures, so that maximum efforts and precautions could be taken to prevent the occurrence of falls.
The most popular approach in health care seems to be the medical approach to health promotion which aims to ensure that the individuals are disease and disability free (Ewles and Simnett,2003).Here the final decision regarding the individual is taken by a health professional, which could be either the doctors or a nursing professionals and the guidelines issued by them are followed by the patient to ensure the safety of the patient and for prevention of falls and the best possible option will be decided by them.
In this session the medical approach may be considered to be the preferred approach when compared with the other approaches, even though it could utilise the aspects of other approaches also during the process. The relevance of medical approach may be summarised through a small case example as follows.
Case example
Thomas was a 75 year male patient, who got admitted to one of the residential homes, after being discharged from the hospital following a myocardial infarction for which appropriate treatment was given. During his hospital stay, , he developed a stroke, with some changes in the CT scan and he suffered weakness of one side of the body with some difficulty in walking. He was first admitted to the intensive care unit (ICU) through the emergency department and after coming to the hospital he suffered a fall, while he attempted to get up from his hospital bed in the ICU, which resulted in a small head injury for him. So as part of the treatment, physiotherapy was advised for Thomas for improving his mobility and weakness problem for which he was transferred to the residential home. Later a detailed investigation was carried out including the clinical history and laboratory investigations by the nurse practitioner in charge which revealed that the had some problem with the vascular clotting factors, which was responsible for the myocardial infarction, which further caused the stroke resulting in weakness and fall. The appropriate treatment was given for the same and after regular exercise and physiotherapy there was dramatic improvement in the condition of the patient and Thomas is now able to walk without any assistance and he never suffered any falls after that.
So here it may be noticed that, the condition of Thomas which was the main risk factor for fall, was identified through the medical approach, after doing the relevant investigations and appropriate treatment. The final decision regarding the case working, investigations and follow up were carried under the supervision of a health care professional team including the nurse practitioner and through this approach the patient was able to recover from his illness without any future falls or problems. But health education as part of the strategy and consideration of the patients wishes regarding the treatment were also taken into consideration during the treatment strategy, which shows that even though the medical approach is the dominant approach used here, some of the other approaches may be indirectly linked in health promotion in such situation, which is essential for the success of any health promotion program.
The choice of approach to health promotion mainly depends on the situation and also the setting. In case of community setting, more importance is given to the educational approach, rather than the medical approach as the steps taken for health promotion are more favoured towards the benefits of a society as a whole than to a particular individual. From this it could be concluded that even though a single approach may be considered to be best in health promotion, it also depends on the other approaches indirectly. The nursing practitioner plays a major role in health promotion through these various approaches including medical, educational and client oriented approach.
There are mainly two methods which could be effective in reducing the risk of falls and preventing them in elderly population within residential homes, which includes primary prevention and secondary prevention. In United Kingdom, general practitioners now have an obligation to offer screening once a year to all the people aged 75 or over and there has been much debate about the utility and cost effectiveness of this screening programme,but it could be used to look for the potential risk factors for falls(Gryfe,1977).In Primary prevention simple assessment of vision ,gait and mobility and appropriateness of regular medication could identify some of those at high risk of falls and interventions in these areas could help to reduce the risk of falling.
In secondary prevention, the principle is based on the fact, that falls are more common in elderly population, who have already fallen, as its very common among these group of population to suffer frequent falls and they have twice the risk of falling and it may be cost effective to concentrate preventive measures focusing on this particular risky group (Tinetti, 1986).The most important aspect of secondary prevention is to identify the cause of previous falls and correcting them if possible. It is usually possible to identify in such patients one or more factors which increase their risk of falling and modification of such factors could reduce the risk of falls in future.
Rationale for selection of the topic
A qualitative study about the older people’s views of advice about falls prevention conducted by Yardley et al (2006), reported that the participants interpreted falls prevention principally as a kind of hazard reduction, restriction of activity and use of mobility aids as a protective measure against frequent falls. The study also suggested that falls prevention advice that focuses more on the positive aspects and benefits of improving the balance may be more acceptable and effective than advice on falls prevention (Yardley, 2006).Chang et al (2004) in his study, which was a systematic review and meta analysis of 40 trials conducted to assess the relative effectiveness of interventions such as multifactorial falls risk assessment, management program and education for the prevention of falls in older adults to either a care or control group reported that multifactorial falls risk assessment and management programme was the most effective component on the risk of falling. The study also reported that exercise interventions had a beneficial effect on the risk of falling and monthly fall rate. It may be concluded from the above study that the risk of falling and the monthly rate of falling in older adults could be reduced by effective and appropriate interventions. The prevalence of falls seems to be more in residential homes among the elderly population, which makes the situation more favourable for health promotion by nursing practitioners.
Some of the key factors in the implementation of prevention of falls education, among the elderly people in residential homes, as suggested by National institute of clinical excellence (NICE,2004) includes case risk identification, multifactorial falls risk assessment performed by healthcare professionals with appropriate skills and experience,multifactorial interventions and encouraging the participation of older people in falls prevention programmes .
Resources identification with relevant literature
Laurence Z (1994) conducted a study to review the epidemiology, causes of falls and falls related nursing injuries in nursing homes and to provide clinicians with a well developed framework to evaluate and treat the residents in nursing homes, who are at risk of falls so that regular evaluations in the nursing home could help to identify the patients at high risk, who could then be targeted for specific treatment and prevention strategies. The availability of proper resources including specialised skills, nursing staff with experience, health care management and counselling team, health care policies and a better access to health care facilities the implementation of a successful health promotion program.
The elderly population in residential homes are susceptible to muscle weakness and gait problems and with advance in age it could create more physical changes that could affect the strength and gait. One of the studies conducted by Murray (1980) mentioned that much of the weakness seen among them in residential nursing homes could be explained by the fact that they are more prone to prolonged bed rest and limited physical activity and other chronic medical conditions such as heart failure, stroke or pulmonary disease. So better residential health care facilities and access to hospitals may be needed prevention of falls in elderly population. The other problems that could be associated with ageing among elderly population include decreased gait velocity, prolonged reaction time; and decreased visual acuity .Some of the nurses have special training in falls prevention in the form of education programs, which helps to develops skills to identify the general practice clients, who are at risk of falls, conduct falls risk assessments and implement falls-related injury prevention/interventions as necessary. It has been found that the frail, elderly population living in institutions are more prone to and have a higher incidenceof falls caused by gait disorders, weakness, dizziness, andconfusion, whereas the falls of elderly people living in community based set up aremore related to their environment (Lawrence, 1994). Ensuring that adequate precautions are taken in nursing care of elderly population could be beneficial for implementation of fall prevention programs in residential homes. Following the national /local guidelines related to fall prevention among elderly by the nursing staff could be helpful in ensuring access to unavailable resources. The problems associated with duplication and overlapping could be avoided by regular discussions among the nursing health care staff, community members and the government bodies.
The recommendations provided in the NICE (2004) guidelines cover the care of older people in the residential homes, who are at risk of falling and older people who attend primary or secondary care settings following a fall. NICE (2004) guidelines include further analysis of the existing trial data, to identify which components of multifactorial interventions are important in different settings and the evaluation of multi-agency falls prevention programmes to measure the impact of these programmes and research into the optimal methods of risk assessment for falls in older people and UK based cost-effectiveness analysis of falls prevention strategies. The clinical guidelines identified by the National institute of excellence will be able to support the implementation of National service frameworks (NSF) for supporting the educational programs for prevention of falls in elderly population in residential settings (NSF, 2001).
Planning and evaluation
The evaluation and planning of health and social care for the elderly people is important for implementation of prevention programs and for this purpose, appropriately the scale of this problem has to be assessed, which requires a number of questions to be answered regarding the risk factors and causes for falls in elderly population in residential homes. This also implies looking at the various mechanisms that maintain the balance most of the time and the age and disease related changes that take place in the elderly, which may compromise the balance. The planning and evaluation may be conducted by the nursing practitioner in charge, making sure that all the guidelines are followed step by step. Its a fact that those older people who are in residential homes are almost certainly frailer and they are probably more liable to suffer from complications of falls (Wilkin etal, 1978).In residential homes usually much of the information regarding the falls comes from the falls register and accident registers maintained by these homes for reporting accidents and falls, which are usually filled for medico legal purposes (Down ton, 1993).
It’s very much difficult and confusing to draw conclusions about the incidence and prevalence of falls in the elderly especially in residential homes as these group of old people are not necessarily comparable and some of the studies look specifically at the falls itself, where as some of them look at the accidents alone. Some studies have shown that it is very common for the elderly people to suffer falls during the day time as expected and this could be due to the reason that falls usually occur during movement or activity of some kind (Downton and Andrews, 1991).
There have been many studies, which have shown increased risk of falls in elderly and the associated risk factors for them including both intrinsic as well as extrinsic risk factors. A combination of intrinsic, environmental and situational factors could decide the real risk of falling in this vulnerable group. Studies have shown that amongst those in institutional care, the young elderly especially those under 75 seems to be more prone to fall and this could be due to the reason that those requiring institutional care at a younger age are mostly physically and/or mentally frail and weaker(Haga et al 1996).
Studies have shown that the prevalence of cognitive impairment (Campbell et al 1981) and dementia (Morris et al 1987) was very much commoner in the elderly group who suffered frequent falls. This is in favor of positive relationship between the underlying risk factors and the chances of occurrence in elderly population especially in residential homes.
The outcomes of the planning and evaluation conducted by the nursing practitioner depends on the method in which the planning and evaluation was conducted. The assessment process could take a long time, as it may need the use of questionnaires and interview between the health care staff and the elderly population of residential homes, but the final outcome will be beneficial to both the health care centers as well as the community.
Detailed and specific action plans
Several scoring systems especially for the assessing the fall risk among elderly in residential homes have been evaluated which includes mobility score, distant vision,hearing,moral score, mental status score, back extension, Orthostatic blood pressure ,medications and activities of daily living score(Tinitti et al,1986).These scoring systems and assessment methods could be used by the nursing practitioner or the health care staff in charge to assess the outcomes and for future planning of health care among the elderly people. It would be sensible to use accident forms, as falls are very common among the elderly population living in residential homes, which could be helpful to identify those fallers who would benefit from further assessment, by the health care staff(Gryfe,1977).There are several aspects of the accident form that need to be considered such as documenting the frequency of falls that may be part of audit of quality of the care of the institutionalized elderly people.(O Brien et al,1987).
Concepts of community health and community assessment
The concept of community health in nursing practice is not very uncommon and forms an integral part of health care nursing practice. The role of community health nurses is to meet its goals by identifying problems within a family for example the prevalence of falls among elderly population in a community (Patricia,2003).They also support maximum community participation by preserving and improving the health services. They focus mainly on the empowerment of the families and communities, which means that they teach the members of a community the essential skills and knowledge needed for them to manage days to day health related problems within the community, which could be helpful to them in making decisions about their own health. More importance is given towards the identification of populations at risk and taking relevant measures needed to reduce the risk among them.
Community assessment in nursing is the process of examining a community’s characteristics, resources, assets, liabilities, and needs in collaboration with the members of the community in order to develop strategies that improve the health and quality of life for the community. The community assessment process involves the following steps such as identifying the available resources, establishing a project team, developing a research plan, collecting and analyzing the information that already exists completing community research using surveys, interviews and discussions, setting priorities for action and planning and implementation of strategies that are selected(Patricia ,2003.
Critically appraisal of the concept of health and illness.
Susan (1998) reported that in nursing practice, the concept of health within illness should be considered as an opportunity to the meaningfulness of life through connectedness or relatedness with the environment and /or awareness of self during a state of compromised well being. It has been also mentioned that the conceptual development of health illness developed through a clinical research based programme. There is much more evidence from nursing literature and from the practicing nurses which further enhances the concept of health within illness concept.
Critically appraisal of approaches to health promotion and health education and their application to specific situations.
There have been various approaches to health promotion and the World Health Organisation (WHO) identified health promotion as a method of equipping people to have more power enabling them to make choices in regard to improving their well-being (WHO 1986).It has been suggested by Ewles and Simnett (2003) from this, that the fundamental elements of health promotion could be improving health and empowerment. Whitehead (2003) in his study reported that health promotion should be considered as a symbiotic paradigm, which helps to bridge the theory and practical gap between them and concluded that the constructive review of any kind of health education or health promotion programme lies in the consideration of each approach according to its own relative merits compared with the demerits and also the nature of the setting in which the intervention usually takes place. The health promotion strategies in nursing field usually uses broader empowerment based and socio-political approaches that make them concerned with the community based economic, social, political and environmental determinants of health (Whitehead,2003). Holloway and Watson (2002) reported that a complete understanding of the processes of patient behaviour is essential for the effective practice of both health promotion and health education in nursing field.
Health needs analysis and application.
Cader et al (2006) has reported in their study that a health needs analysis assignment may be included in the pre- registration nursing programme in order to help the students to develop the adequate knowledge and skills necessary for providing essential evidence based practice in nursing. Studies have shown that this could be made possible by creating an awareness and understanding among the pre registration nursing students, the importance of evidence based practice and inclusion of the same as part of their general nursing curriculum in which an analysis of the health needs of a particular client group is undertaken,(Clegg and Doherty, 2001).The same study also mentioned that health needs analysis has to be viewed as the most important first stage in any health promotion cycle, and that it should be considered as an integral component of every health care professional’s role, essential to the delivery of every health care professional’s role and modern health care(DOH,1999).The main challenge for the health care professionals is the incorporation of the same into everyday practice to make sure that the delivery of health care that is cost effective and of high quality and evidence based practice.
Ethics of public health programs (rationing resource targeting and equity)
Ferruci (2004) in his study reported that inability to consent by the elderly population should not be considered as an absolute criterion for exclusion, while considering interventions for prevention of falls among the elderly. The lack of full capacity for consenting by the frail older persons in residential homes raise ethical and legal dilemmas in the implementation of educational prevention programs for prevention of falls among elderly population.
The other major ethical issues include the problems with the acceptance of these health promotional activities by the elderly population. Frederich( 2003) in his study on the primary rationing of health services in ageing societies concluded that any collective financed health system that usually does not make use of any limitation of resource effort and therefore without any kind of primary rationing would neither at present or in future be conceivable or desirable. So it seems to be more adequate and better to discuss the rationing by looking for any kind of justifiable forms of primary rationing rather than depending or focussing on the problem of just allocation of scarce medical resources on the secondary level of rationing. There have been various opinions regarding the use of age as a proxy indicator of an individual’s health status and the extent to which age could act as a reasonable proxy depends on the specific condition and may vary accordingly. Williams (1997) in his study has reported that age may be considered as the best single predictor of increasing health problems even though it cannot be considered as a determinant of health on a broader view. Kapp (1998) also in his study argued that age should not be considered as dependable proxy for the medical prognosis of individual patients, despite its general utility.
Conclusion
To summarise, it’s very common in old age to fall and their stability and tendency to fall is very much widely recognized and sometimes rightly or wrongly accepted as a fact of the ageing process. Falling, among elderly population has got an impact on the quality of life, health and healthcare costs.Most of the time the assessment of treatable problems is delayed, which could result in permanent disability and dependence. There are many significant medical, social and economic consequences that could follow from this kind of tendency of old people to fall and this is very important with the potential increase in the number elderly people especially the very old people especially in residential homes and old age homes(Downton,1993).With a problem of the magnitude of falls amongst elderly people in residential homes ,with the functional and economic consequences that have been demonstrated, thought needs to be given to whether either falls or their consequences can be prevented. . It has been found that although primary prevention of falls and their complications is a mammoth task and may not in practice be cost effective, consideration of the various aspects of primary prevention is useful to provide pointers towards areas which could provide benefits for elderly fallers and potential fallers.