Human Computer Interaction

Katelyn Harth

2-2 Rough Draft of Sections I & II of Change Proposal

Southern New Hampshire University: NUR 490

September 5^th, 2021

Hospital Acquired Falls

The purpose of the paper is to educate people on a professional practice issue and decrease the occurrence of falls in healthcare settings. Health care is not always perfect, and mistakes do happen, but some mistakes, such as hospital acquire falls, can lead to the demise of a patient and their health. Falls are a major problem that has been seen in a number of health care facilities. Without proper precautions or assessments patients can experience falls and become at risk for further health complications and possibly even death. This can have an impact on the nursing practice because it leads to the patient needing increased attention the nursing staff. It can also lead to the nursing staff receiving consequences for not assessing the patient properly or placing the proper precautions on the individual at risk. Educating those in healthcare on ways to prevent falls from occurring is important not only to the professional but the patient’s health as well. With the correct preventions, it can save a patient’s life from further deterioration.

Justification of the Need for Change

Falls still remain to be a substantial problem and are one of the most common adverse events recorded by hospitals each year. Hospital-acquired falls are not only dangerous and can lead to further complications for patients, but they are also costly for the health care facility it occurs in. “Each year, roughly 700,000 to 1 million patients falls occur in U.S. hospitals resulting in around 250,000 injuries and up to 11,000 deaths” (LeLaurin &Shorr, 2019, p.273). Out of all the patients who are hospitalized, 2% of them fall at least one time during their admission. “Approximately one in four falls results in injury, with about 10% resulting in serious injury” (LeLaurin & Shorr, 2019, p.273). Falls can be related to the age of the patient, medications being taking, a cluttered room, the mental status of the patient, restraints being used incorrectly or the patient’s current injury or illness. Fall prevention is crucial to decrease the number of incidents that occur.

“Falls with injury are a serious and prevalent safety issue in U.S. hospitals, costing over $14,000 per occurrence (The Joint Commission, 2015). As of 2008, Centers for Medicare & Medicaid Services (2020) stopped paying for costs associated with inpatient falls if the fall was preventable. Despite interventions, falls continue to be one of the most reported safety events. Use of evidence-based fall prevention strategies is imperative to confront the problem” (Rohm, et al., 2020, p. 303). Because Medicare and Medicaid stopped paying for fall associated injuries, hopsitals are reliable to pay the care provided to patients, which can become a large sum of money (Leaf Healthcare, 2016). “According to the United States (U.S.) Centers for Disease Control and Prevention (CDC), falls contribute to more than 2.8 million incidents treated annually in emergency departments, including more than 800,000 hospitalizations and more than 27,000 deaths (National Council on Aging (NCOA, 2020)” [CITATION Fer21 p 1 l 1033 ].

Nurses are resposbile to care for each patient effectively and efficiently. When they have a large workload it becomes difficult to manage patient care and tasks can fall through the cracks. Nurses are on the front line of decreasing the risk for falls, but this becomes challenging when nurse to patient ratios are off. Patients depend on the nurses to offer safe care, however when the staffing ratios are scarce to provide appropriate care, the patient suffer. The ratio issue is one that could be spoken about for hours but in relation to falls, a busy nurse fails to pay attention to important details when there are a million things to juggle. “Nurses are responsible for assessing patients for fall risk and implementing fall prevention methods to prevent an actual fall. Despite nurse efforts, many falls still occur. The question is, are the falls related to understaffing. Most health care providers would agree that more nurses can provide safer and better care, but research supporting this has been inconclusive (Heet al., 2016)” [CITATION Fer21 p 2 l 1033 ]. How is a nurse expected to care for seven patients effectively and without complications, if all seven patients are high-risk or require multiple nursing tasks? Each time they are in a patients room, it takes away time that could be spent focusing more closely on a patient who is a potential risk to themselves. Staffing becomes an issue when patients are being harmed while in the care of a health care professional who is supposed to be protecting them from further complications. Managers and administration need to step in and attempt to staff the units more sufficiently in order to prevent these types of occurances.

Enviornemntal factors can become an issue related to falls which can be prevented. Patientes have reported that their call light was not within reach for those who needed assistance ambulating to the bathroom. Another instance is the patietns who had only one or no side rails up while laying in bed [CITATION Als18 l 1033 ]. For the patients that are not able to ambulate well on their own or at all, their environment needs to meet those needs in order to allow them to access personal belongings, tolieting rights and freedom from their beds if their health condition permits it. Assisting patients to the bathroom, or helping them up to sit in the bedside chair is still apart of nursing care. When the enviroment does not allow for these circumstances to take place the health care staff are the ones who need to make sure the patient is comfortable and can have access to them. If a spill occurs on the floor and it is left there or no one notices it, the patient can be getting up to grab personal items or use the bathroom which then causes them to slip and fall. Now they are at risk for life threatening injuries and a longer hospital stay depending on how severe the fall was.

Change Theory

Changes are inevitable and are happening constantly in the healthcare world. With new technology emerging, procedures and practices are changing with them as well. Although change can be difficult for some, finding a change model to mirror can make the transition easier. The Lippitt change theory demonstrates seven steps for implementing changing in the nursing field and is said to be one of the popular theories of change in the nursing community because it allows for a look at change through the managers viewpoint.

The first phase of the model is diagnosis the problems. “When applying this stage to managing change in nursing, this can be articulating the reason for the change, so everyone understands what the problem is and why the change is necessary” [ CITATION Air20 l 1033 ]. Since the topic of the paper relates to falls within the hospital setting, it would be fair to say that understanding why falls are occurring could be categorized into this first phase. Is medication, environment, age or orientation leading patients to fall during their stay? Determining the cause for the falls is the initial first step in creating change.

The second phase is to assess the motivation and capacity for change. Are there any barriers in the nursing field that will allow for a change to occur in relation to falls? Deciding if staff is ready to make a change is a limitation that needs to be discussed because it can affect the entire effort of enforcing a shift. The third phase presented in this model assesses the resources and motivation of the change agent. Will the staff be willing to help initiate the change and encourage the new system that is going to be put into place? Finding these individuals who will help drive the change will be found once the second phase is complete and management finds those employees who are not resistant to the shift but are encouraged by it.

The fourth phase is about choosing progressive change objects. “This is the phase in the Lippitt change theory where you’ll create your action plans to facilitate your change management in nursing” [ CITATION Air20 l 1033 ]. This includes communication, education and training on the new systems. The first phase is about ensuring the roles and responsibilities of change agents are clear and understood. The members of the nursing team who will help enforce the new model will need directions on how to help motivate others. Determining who will be explaining the facts of the new system, and who will motivate/encourage the rest of the staff can defuse messy situations against those who are resistant. It will also decrease any confusion that may be present about certain topics and allow the “change agents” to be proficient in one specific area of the implementation process.

The sixth phase is about maintaining the change through communicating, feedback and group coordination. “Once you’ve implemented the changed in the healthcare processes dictated by your change project, it’s important to provide continued support, communication and invite user feedback so you can ensure the change sticks and is maintained” [ CITATION Air20 l 1033 ]. The final stage is about ending the change support and removing the change agents from the equation. At this point the change should be second nature to all nursing staff and is another task that is a part of a nurse’s daily tasks. “This should happen once you’ve confirmed the change is now part of the organizational culture and has become “the way we do things”” [ CITATION Air20 l 1033 ].

References

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