It’s out of doubt that the long-term nursing care experiences a lot of difficult situations, and one of them is a wide-spread problem of patients’ falling. As it is stated in the article How staff and families can improve communications, falls are the most common resident safety issue in long term care settings (Wagner, & Mafrici, 2007). According to the statistic data, there are about 2 million people in America living in nursing homes. By 2020 this figure will expectedly reach 3.4 million. In other words, one third of adults who are older than 64 years of age and live outside of institutions, fall annually, and the older the resident, the higher risk of falling. From 45% to 70% of residents of long-term care nursing houses fall each year. About half of those fall more than once a year (Greubel et al., 2002). In a 100-bed nursing house, there will be approximately 100-200 falls per year (1.5 falls per bed annually), and a lot of residents are likely to fall more than once. It is also traced that in the long-term care sitting the older residents experience from two to three times more multiple falls than those who are community-dwelling. The latter also suffer less from the consequences of hip fracture (on average, only 4 % of falls are leading to it, nevertheless, the risk is higher for nursing home patients and can even get mortal character:
“Two-thirds of community-dwelling and institutionalized adults with hip fractures die within a year of injury” (Rubenstein et al., 1994)).
10-25 % of falls taking place in nursing homes result in fractures and hospitalization . It is a frightening statistics because falls are not dangerous themselves, but they result in many serious injuries and disorders: higher incidence of morbidity, immobility, and mortality on the whole by the way contributing essentially to depression and social isolation, to functional decline, and nursing home admission. This problem also makes the general treatment more expensive and long:
“the population lifetime cost of injuries associated with falls averages $12.6 billion, and the average hospital charge for fall – related injuries in an older adult is $11,800” (Tinetti, 1994).
As for the most spread reasons of falls, there is a range of factors defined: a half of incidents is caused by furniture, and 90 % of falls occur when staff member is away. Most of the falls take place between ten in the evening and half past six in the evening. This period is known for low presence of staff members.
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Further, when defining the situation with falls, we should come up with the terms. The word fall stands for “an event that results in a person coming to rest inadvertently on the ground or other lower level” (Ray et al., 1997). It is significant to determine the two main categories of reasons of falls: intrinsic (referring to the individual condition of a person) and extrinsic (related to the environment). As for the intrinsic factors of risk, the most common are disturbances with gait and balance (impair gait, short stride and step, postural sway increased), then visual disturbances and dizziness, musculoskeletal diseases, weakness and confusion, syncope, delayed reactions, environmental hazards, and naturally the effects of medications (psychotropic drugs, diuretics, antidepressants, antihypertensives, hypoglycemics and hypnotics). Deborah Greubel (2002) stresses that there also unanticipated risk factors like seizures, cerebrovascular accidents, transient ischemic attacks, and “drop attacks”. All these factors are gathered to the history of falls of the patient.
In my view, falls are a serious examination for a nurse. Dealing with this problem face to face can train a nurse for many other challenges, as it demands involvement before and after the fall itself. In order to take preventive measures against falling among older people a nurse should to be not only a good medical worker, but also practice her understanding of people, of the most delicate shifts in their moods and states. A lot of capacities are to be developed to make a nurse careful and effective in intervening to the falling as well as organizing supportive actions. As for the latter, the nurse is also engaged in building up a team that is intended to take away the physical and moral pain of the patient.
As we know, nursing is focused on providing optimal health and high quality of life. Under this task, it deals with many specialties and makes the nurse work in different conditions, at homes and hospitals, at schools and pharmaceutical companies. In long-term care facilities they also have their specific features and make the nurse the nearest person for a dwelling patient. It is obvious that falling in nursing practice is joined together with other challenges, which teaches the nurse to be not only caring, supportive and professional, but cooperative as well, as there may a lot of difficult and unexpected situations which can bring the nurse to a deadlock. Still, the other staff members will be helpful to cooperate with. The main thing is to work thoroughly with reasons and to take preventive measures.
As we have already admitted, environmental forces play a great role in the situation with falls among long-term care residents. Environment refers to extrinsic risk factors. Speaking in details, these factors include wet floor, floor glare or poor lighting, crowned room, absence of problems with handrail support, loose cords or wires; problems with shoes; low or uncomfortable toilet seat; beds or chairs with wheels as well as beds being too high; restraints (for example, when side rails are left in the up position); unsafe and broken equipment and other (Hignett and Masud, 2006). Environmental surroundings belong to the factors that can be easily modified, in contrast to individual patient’s fall history. Preventive measures are summed up and formulated by Laura Wagner and Nina Mafrici. So, we should escape: 1) physical obstacles in the building itself, for example cleaning equipment left in passageways or some furniture met where residents may walk; (2) irrelevant assessment for risk of fall; (3) improper functioning of a patient’s safety equipment (especially intravenous lines, catheters, and oxygen); (4) bad internal design; (5) insufficient supervision (Wagner, & Mafrici, 2007).
All these factors are rather difficult to prevent strictly, and it goes without saying that entering a long term care facility is difficult emotionally and presents a challenging experience for most of residents and their families as well. However, effective collaboration of patient’s family and nurses can be resultant. Laura Wagner and Nina Mafrici (2007) prove that “open and honest communication between staff and family members is actually a key factor.” It is important that both the family and the stuff take responsibility and are aware of their obligations intended to help the patients. The family members should track all the events to the history of falls, inform the staff of any behavioral changes and control whether the environmental conditions are proper in the nursing house (is the alarm system working properly? Aren’t there any hazards which are provoking falls? Is the equipment working efficiently and carefully?). The family should take care of what the patient is wearing (shoes with high heels are dangerous as well as slippers). Meanwhile the staff is to inform the family of each incident no matter at what time of the day or night it takes place. The family members should know all the details, the reasons and the guilty should be found but the nurse shouldn’t make excuses for each. The staff should also share their program of actions for overcoming the troubles. All the nurse team with a charge nurse in the lead should find an opportunity to interact with the family on a regular basis. It is important to realize for all the involved that families and staff are companions in care-giving. It is wise for care providers to recognize that each patient’s family faces individual preferences, has individual values and own beliefs regarding the care of their nearest. Due to those diversities, the staff should be sensitive and attentive to the issues and concerns of falling among the residents. A “caregiver coalition” should be organized and there both families and staff should struggle for uniting into an interdisciplinary team. The purpose of it is to discuss resident care planning continually involving the families as much as possible. This is the way to satisfy the need for mutual trust, respect and understanding between the interested parties.
Still, whatever supportive families and staff are, the problem cannot be overcome without special methods. Accordingly with general reasons and individual characteristics of a patient, there are several strategies on fall intervention. Lately there has been a serious shift in preventing falls of residents. Before recent times, all fall reduction programs were concentrated on physical restraints. But this was not the perfect way out. Bed alarm systems were found not very effective either, as for them to work properly, staff members must be constantly ready to react. Assessment tools are being tested at the moment. Progressive method is to identify individual peculiarities of resident’s falls, to patient and to decline the risk of falling by changing the environmental conditions (Cannard, 1996).
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Earlier we have reviewed most problems coming from falls among older residents. But if were touch the problem of challenges rising from the issue, we should underline that there are not only physical restraints and troubles faced by patients, but psychological declines as well. Falling and its consequences give birth to new, often uncontrolled fears, and patients find themselves confused to do many normal things they never had problems with before: “As well, besides the physical consequences of falls, there is also a psychological component where victims experience fear of falling and thus decrease in their willingness to perform functional activities such as bathing, dressing and walking,” Deborah Greubel (2002) says. Psychological problems can turn even an insignificant fall into a dangerous challenge.
Hence, falls as a nursing challenge are also followed by a range of social, ethic and legal problems. The fall itself is morally embarrassing for a person, but even more stressing are the consequences of falls which make it difficult for a patient to stay socially adopted and a sound member of the community. It is also ethically difficult for a patient and for his family because on the one hand the family feels guilty for not providing enough support at homes where patients usually feel more comfortable and safe. But on the other hand, they are often busy and have no enough time, knowledge and other resources to be really helpful for their relative. Long-term care facilities are specially working to help them, but leaving homes may make the patients depressed and separated from their nearest and dearest. Further, families can sue the nursing home for patient’s injuries and even death as it was, for example, with one elderly person in Virginia. The nursing experts are tested and can loose their work even if there is no blame of them. That is a reason to take down all the notes on patient’s history of falls. Besides, to set up the appropriate standard of care, expert testimony is necessary to be provided. It helps to identify the deviation from the standards of care and estimate the legal aspect of the lawsuit.
But to make the service really effective, many improvements are needed. Many tests are performed at the Yale University Fragility and Injuries Cooperative Studies of Intervention Techniques. There was a system of steps developed to increase the quality of service provided for falling patients in long-term care houses. They include: gathering the history of falls of the patient; estimating the risk of future falls; determining the nature, regularity and reasons of falling of the individual; defining actual and potential complications a patient faces; working out a system for controlling falls and determining fall risks; managing the causes of falling; monitoring falling in details; and eventually conducting quality improvement activities for fall prevention. The proper guidelines include educational recommendations, practice recommendations and organizational policy recommendations. Norris and her team underline the use of systematic review and propose “multifactorial intervention program for long-term care residents to prevent falls and reduce the rate of injuries. Residents should be assessed on admission and re-assessed after a fall”; structured multidisciplinary programs targeted solely to groups with high risk; moreover, “all persons admitted to LTC should undergo a comprehensive and individualized risk assessment of the broad range of intrinsic and extrinsic risk factors” and a program on multi-factorial intervention should be developed for each resident individually to reduce extrinsic and intrinsic risk factors (Norris et al., 2005).
Unfortunately, social and legal problems are not the only. Even having a lot of good strategies proposed, many nursing long-term care facilities can’t afford to employ enough nurses to provide continual control and supervision, the modern equipment is also unavailable for many of them and due to that environmental problems stay unsolved. Besides, some families can’t afford long-term care and therefore leave the patient at home where risks increase and more work for physicians appears.
Therefore, current research should be aimed at making the service more available. There are many organizations that conduct studies on this or that matter of the problem of falls. American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopaedic Surgeons Panel on Falls Prevention have developed guidelines taken from epidemiological studies. The study listed staff education programs, assistive tools, then inclusive assessment, and also cutback of medications as the most effective interventions. American Medical Directors Association developed guidelines based on evidence-based and consensus-based thinking. Registered Nurses’ Association of Ontario used scientific substantiation on the impediment of falls in the aged people living in health care settings and has served as a assistive tool in decision making process for individual falls. The research provided by the Registered Nurses’ Association of Ontario was conducted with a purpose to help nurses in identifying general and individual risk factors for falls, and to decline the occurrence and heaviness of falls. Other organizations working out specific guidelines are National Resource Center for Safe Aging, Baycrest and the Ontario Long Term Care Association, Association for Gerontologic Education and others.
Nevertheless, there are still many aspects not developed enough to provide appropriate scientific base for nursing practice. So, there is a vast space for further research. For example, there is a lack of literature on falls coming from dementia. Deborah Greubel (2002) finds it a separate issue. The matter is, she explains, patients with dementia, especially those who have lower mental status scores, get under a high risk of falling. Patients with dementia experience more trouble with judgment, visual-spatial perception, and find it difficult to orient themselves well to surroundings. Demented patients more often have impaired motor function; the symptoms of advanced dementia and Parkinson’s disease include gait abnormality too. Accordingly, the overall risk of death increases with dementia and Parkinson’s disease. Therefore, more research is needed in this field.
Then, there are very few studies on multi-factorial interventions and their efficacy in long-term care settings. These tools are found rather effective, but not much literature is studying it thoroughly and there is only one work discovering their disadvantages. Apart from those specific topics, there are many other challenges that need laboratory estimation and further study.
In this way we have discussed the complex nursing situation connected with falls of patients in long-term care houses. We have discovered that there is a system of dangerous factors leading to the formation of this situation and found out that the first step in preventing falls is to study the reasons of falling. This must be with individual approach to each person, as the causes may vary depending on age, sex and other demographic indexes. If falls are multiple (and they usually are), there should be a history of falls of each patient. It helps to estimate the risks and improve the environmental conditions for a patient. Many assessment tools are developed to help the residents of long-term care facilities, but still there are many problems in the sphere. More government assistance is required, and there is still much scope for further research.
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