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Guidelines for the Implementing Evidence Based Practice summative assignment

‘Summative Assessment: 3000 words (+/- 10%)assignment will be on a topic of the student’s own choiceor from the list provided;identified from practice experience and of relevance to service users and their families’ care experiences’

The topic must be focus on improving patient safety and/ or patient experience.

Examine the evidence supporting a clinical topic (chosen from your clinical experience) and critically appraise the evidence to underpin the evidence based practice, including a discussion of factors that may inhibit the implementation of the evidence base.

The Introduction

Introduce the research question and highlight any lack of evidence in the literature

Research question

Rationale for asking this question-why are you asking this? Is there a lack of evidence in the existing literature?

Introduce how you formulated your question

You must use PICO/PEO to clearly define your question.

Aims and objectives of this review

Methodology

You need to look at the evidence base for your chosen topic. This will require good literature searching skills and a clear account of the search strategy you used. 6-15 papers are recommended but there may be more or less depending on your question.

Describe search terms used

Inclusion/Exclusion criteria

Results of the search strategy

Describe your findings and use a table to depict results and place in appendices

Quality Appraisal

Use an appraisal tool to appraise the papers you have selected. Put this information in your appendices and refer to it.

Mention bias in terms of research methodology for the papers you have selected

Summary and synthesis of the papers

What are the main points of the literature in relation to your research question?

Are there any themes coming through? Is there a reliance on particular areas?

Issues of Implementation

For the last quarter of the assignment (roughly) you are encouraged to use a framework such as PARIHS to explore issues of implementation.

Conclusion

Complete the essay with a brief conclusion drawing together the key ideas that specifically answered your research question and finally the implication of your findings for practice.

Above all make sure you are being critical in a structured and logical way

MY RESEARCH QUESTION IS“What are the best strategies used to reduce falls in the elderly people inlong-term care homesUSING PICO.
after reference
appendix

Table 2 Example

REFERENCE	AIMS AND OBJECTIVES	METHODOLOGY	FINDINGS	CONCLUSION WITH REFERENCE TO TOPIC QUESTION
Aranda-Gallardo, M., Morales-Asencio, J.M., Enriquez de Luna-Rodriguez, M., Vazquez-Blanco, M.J., Morilla-Herrera, J.C., Rivas-Ruiz, F., Toribio-Montero, J.C. and Canca-Sanchez, J.C. (2018), Characteristics, consequences and prevention of falls in institutionalised older adults in the province of Malaga (Spain): a prospective, cohort, multicentre study,BMJ Open, (82) p. e020039, DOI: XXXXXXXXXX/bmjopen XXXXXXXXXX.	The aim was to determine the characteristics of people at risk of falls, the harm caused and the relationship between falls and the prevention methods used	A quantitative approach with a prospective cohort design. 37 nursing homes with 896 residents recruited. Descriptive analysis.	Fall prevention strategies used were: bed rails physical restraints and suspension ofpsychotropic medication	The fall prevention such as physical restraints are aim at limiting mobility which are resulting in more falls
Gill LM, Englert NC. A music intervention's effect on falls in a dementia unit.J NURSE PRACT. 2013;9(9):5 DOI: XXXXXXXXXX/j.nurpra XXXXXXXXXX.	To test the hypothesis that music will reduce falls in institutionalized persons with dementia	A quasi-experimental design, variant of a cluster randomized trial convenience sample with 39 participants data analysed with SPSS, t test	Non-significantly difference was found however, the level of agitation was noticeably diminished with the music intervention. Which can then reduce falls.	Dementia is identified as one of the risk factors of falls. Calming environment is revealed to reduce falls.
Robertson, K, Logan, P, Ward, M, Pollard, J, Gordon, A, Williams, W & Watson, J 2012, ‘Thinking falls -- taking action: a falls prevention tool for care homes’,British Journal of Community Nursing, vol. 17, no. 5, pp. 206–209,	Aim not declared. However, the implied aim was to test the implementation of a fall risk assessment checklist,	A quantitative approach Purposive sampling of 10 care homes 4 nursing homes with 26 residents. Descriptive	The checklist identified fall risk in individual	Identifying risk factors will prompts actions and thereby reduce falls
Gietzelt, M, Feldwieser, F, Gövercin, M, Steinhagen-Thiessen, E & Marschollek, M 2014, ‘A prospective field study for sensor-based identification of fall risk in older people with dementia’,Informatics for Health & Social Care, vol. 39, no. 3/4, pp. 249–261,	The aim was to find out if gaits episode can give a fall prognosis in the cohort of older adults with dementia.	A quantitative method. Longitudinal cohort design 40 participants however 12 dropped out. TUG MMSE.A field study. MySQL data Base. An accelerometry-based gait Analysis to predict falls.A decision tree induction method to analyse data.	concluded that there is correlational relationship between the gait pattern which can then produce fall	Gait problems is one of risk factors of falls to fall which can prompts action in reducing falls
Szczerbinska, K, Zak, M & Ziomkiewicz, A n.d., ‘Role of method of implementing multi-factorial falls prevention in nursing homes for elderly persons. The EUNESE project’,AGING CLINICAL AND EXPERIMENTAL RESEARCH, vol. 22, no. 3, pp. 261–269,	The main aim was to assess the effectiveness of two types of implementation of multi-factorial intervention to reduce the incidence of falls in three nursing homes (NHs):	A quantitative approach with observational design. A randomised sample of 3 care homes with 222 participants.	A significant drop in falls is noted in the homes where the staff the prevention program was fully adopted by the staff directly involved in providing residents.	Whole staff involvement in the risk falling assessment is effective and low cost than employing specialist inputs
Walker, GM, Armstrong, S, Gordon, AL, Gladman, J, Robertson, K, Ward, M, Conroy, S, Arnold, G, Darby, J, Frowd, N, Williams, W, Knowles, S & Logan, PA 2016, ‘The Falls In Care Home study: A feasibility randomized controlled trial of the use of a risk assessment and decision support tool to prevent falls in care homes’,	A quantitative study using a two-centre, single-blind, feasibility, cluster randomized controlled trial Purposively sample 52 participants from 6 care homes of Age 50 years and above, Barthel Index1, Descriptive and statistical analysis	Falls were reduced in the control group.	Training, leadership and senior involvement from managers to promote compliance with documentation Increased fall vigilance Staff turnover, increased communication	Fall risk assessment checklist can reduce falls in the care home setting.
Wang, Y-C, Lin, F-G, Yu, C-P, Tzeng, Y-M, Liang, C-K, Chang, Y-W, Chou, C-C, Chien, W-C & Kao, S 2012, ‘Depression as a predictor of falls amongst institutionalized elders’,Aging & Mental Health, vol. 16, no. 6, pp. 763–770,	The aim was to assess the joint effect of depression status with other medical condition on falls among the elderlypeople institutiolised	A quantitative approach with cross sectional design. A sample size of 286 participants from 4 care homes. A structured questionnaire and interviews to generate data. Test -retest and nonparametric Wilcoxon signed-rank test. PASW Statistics	participants that were depressive with other adverse health and medical conditions were about 5-11 times at risk more than participants that were not depressive and free from other health and, medical conditions	identifying depression in people with medical condition can serve as a strategy in reducing falls among elderly people institutionalised.
Lannering, C., Ernsth Bravell, M. and Johansson, L. (2017) ‘Prevention of falls, malnutrition and pressure ulcers among older persons - nursing staff’s experiences of a structured preventive care process’,Health & Social Care in the Community, 25(3), pp. 1011–1020. doi: XXXXXXXXXX/hsc.12400.	To describe nursing staff, experience on the use of a systematic work structure checklist developed to improve quality of preventive care which will thereby contribute to reduce falls, malnutrition and pressure ulcers among older people.	inductive qualitative design. 44 participants group into eight focus group. Interviews.	The structured work flow appeared to only be working partly in facilitating the quality of care.	Formal structure of work was not really needed in everyday care. Observations and individual risk assessment can reduce falls.

List of studies with the data extracted

Table 3

Yes =2, P= 1, N=0

NO

18 Question from Caldwell tool

1

2

3

4

5

6

7

Variation for Qualitative paper tool

8

1

Does the title reflect the content

y

Y

y

Y

y

Y

2

Are the Authors Credible

y

Y

y

Y

y

Y

3

Does the Abstract give key summaries of the components

y

Y

y

Y

y

Y

4

Rationale for undertaking the research is it clearly outlined

y

Y

y

Y

y

Y

5

Does it have a comprehensive and UpToDate literature review

y

Y

y

Y

y

Y

6

Does it have a clearly stated aim for the research

y

N

y

Y

y

Y

7

Does the study clearly identify and addressed the ethical issues

y

P

Y

y

P

Y

y

Y

8

Is the methodology identified and justified

y

P

y

Y

y

Y

9

Does the study design clearly identified and the rationale for the choice of design evident.

y

P

y

Y

y

Are the philosophical background and study design identified and the rationale for

P

10

Is there an experimental hypothesis clearly stated are the key variables clearly defined

N

y

N

y

N

p

Are the major concepts identified

N

11

Is the population identified

y

Y

y

Is the context of study clearly outlined

Y

12

Is the sample adequately described and reflective of the population

y

Y

y

Y

p

Is the selection of participants described and the sampling method identified?

P

Example of :A literature search was carried out using the following electronic databases, Cinahl, Medline, PsycArticles, PubMed, and PsycInfo, to generate suitable studies needed for this research question. The research topic was broken down into the following keywords ‘older adults’, elderly, geriatrics, strategies, methods, techniques, ‘falls prevention’, ‘reduce fall’, ‘residential care home’, ‘nursing homes’ and ‘long-term care homes’ using truncate and Boolean operator ‘OR/AND to narrow and combine relevant search terms. A total of 99 articles were generated from these search methods. Inclusion and exclusion criteria were then applied to select the relevant papers. The search journal was restricted to the years XXXXXXXXXXand this reduced the papers to 34 papers. Further Inclusion and exclusion criteria such as age specified as 65 years and above, academic journals, and language setting to English were all applied. These yielded 13 papers. These studies were further evaluated through full text and the study that were not fit into the criteria were removed and the best 8 papers were selected.7 quantitative papers and 1 qualitative paper. See table 1

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Sunabh · Accepted Answer

IMPLEMENTING EVIDENCE BASED PRACTICE SUMMATIVE ASSIGNMENT
Table of Contents
1. Introduction	3
2. Research Question	3
3. Formulation of the Research Question	4
3.1 Aims and Objectives	4
4. Methodology	4
4.1 Prisma Flow Diagram	5
5. Quality Appraisal	6
6. Summary and Synthesis of Papers	6
Article 1:	6
Article 2:	7
Article 3:	7
Article 4:	8
Article 5:	8
Article 6:	8
Article 7:	9
7. Issues of Implementation	9
8. Conclusion	10
References	11
Appendices	13
Appendix 1: Caldwell Tool	13
Appendix 2: Literature Grid	15
1. Introduction
Long-term care homes could be one of the safest places for elderly individuals concerning the planned and personalised care elder individuals receive. However, it would be essential to consider that falls among elderly individuals is one of the most common issues. Elderly individuals have been reported to fall at an average of 2.6 falls per person every year. Falls among elderly could result into disability, reduced quality of life, functional decline, serious injuries and even death. Moreover, long-term care homes are developed to provide care for the elderly and keep them away from injuries yet, it is reported that approximately 1800 elderly individuals residing at nursing homes or long-term care facilities die from falls every year. 
Patient safety is one of the most essential concerns of care homes. Therefore, there is a need to identify and implement certain strategies for elderly fall reduction. This paper will reflect upon the presented issues that is, ‘best strategies, which could be adopted to reduce falls in elderly’. Further, efforts will be made to present clear aims and objectives for this paper. Likewise, this paper will provide a descriptive methodology of conducting research along with exhaustive summary or synthesis of selected papers. Accordingly, the paper will end with certain issues associated with implementation of proposed strategies. 
2. Research Question
As mentioned above also, falls pose a serious risk to all the elderly individuals living in long-term care facilities. It would be essential to understand that these long-term care facilities are designed or planned to eradicate any risks for the elderly, yet falls present a major risk. Lee and Kim (2017) presented that despite of serious efforts, an average nursing home with 100 beds reports 100-200 falls annually. Likewise, Willy and Osterberg (2014) suggested that 50-75% of nursing home residents, especially elderly fall annually. Fall is a serious concern among elderly because it results into injury or serious threat to life for the elderly. 
Cameron et al. (2018) mentioned certain risk factors, which could be held responsible for frequent or unpredictable falls among elderly such as, poor vision, history of chronic diseases, vertigo, balance problems and much more. Further, out of all these factors, imbalances, inability to maintain balance or fear of falling were the most prominent factors facilitating falls among elderly in long term care centres. It would be essential to consider that beside prior mentioned intrinsic factors facilitating fall, there can be number extrinsic factors such as presence of obstacles, unavailability of care providers, lack of resources and much more leading to falls among elderly. 
Therefore, considering the above presented arguments and evidences, it could be proposed that extrinsic factors facilitating fall among elderly could be controlled and eradicated because they are under control of care providers. Hence, this paper will focus upon 'what best strategies could be used by long-term care homes to avoid falls among elderly?' 
3. Formulation of the Research Question
It would be essential to consider the fact those extrinsic, rather than intrinsic, factors facilitating falls among elderly could be controlled by long-term care homes. Therefore, this research will use PEO (Patient, Exposure and Outcomes) as the framework for formulation of research question. 
Patient - The research will focus upon elderly individuals that is, age group of 60 years and above.
Exposure - New strategies for fall reduction among elderly, identified from the available literature.
Outcomes - Significant reduction in current elderly fall percentage upon proper implementation.
This research would also enlighten the question "Are current strategies used by long-term facilities effective in reducing falls among elderly?" Nevertheless, the paper would focus upon answering "What could be the best strategies for elderly fall reduction in long-term care facilities?”
3.1 Aims and Objectives 
Aims and objectives of a research plays a major role concerning successful or compliance to anticipated outcomes. Major objective of this paper will be to identify some of the best strategies, from prior published literature, to prevent falls among elderly in long-term care facilities. Further, another objective would be to identify the effectiveness of proposed strategies and then retrieve some of the most effective strategies.
Therefore, aims of this paper will be,
· To identify possible factors facilitating falls among elderly
· To analyse the potential sources of those factors
· To retrieve best strategies for preventing falls among elderly based upon available literature
· To present effective strategies for preventing fall among elderly in long-term care facilities
4. Methodology
Methodology of a research plays a major role when identifying the overall reliability and validity of the research. In order to continue with the aims and objectives, a secondary research was performed. 
A search was carried out using databases such as MEDLINE, PubMed and Google Scholar. These databases were easy to access and most of the available literature was freely accessible. In order to search for literature, research question was fragmented into several key words such as 'elderly fall', 'factors responsible for fall among elders', 'elderly falls and long-term care facilities' 'strategies to prevent fall among elderly'. Further, the search strategy included the use of Boolean operator 'AND' in order to form various combinations of keywords.
Overall, n= 873 results were obtained after searching all three data bases that is, PubMed, MEDLINE and Google Scholar. 435 duplicates were removed and remaining n= 438 articles were selected to be screened using inclusion exclusion criteria. Inclusion criteria allowed articles, which were published after 2012 and complied with the keywords. Articles published before 2012 were not included and articles, which only defined factors responsible for elderly fall were excluded. 
Implication of inclusion-exclusion criteria refined the total number of articles to n=87. These search results were then screened based upon PICO and upon consideration of filters such as 'full text only' removed 80 other articles while leaving n=7 articles to be reviewed by this study.
4.1 Prisma Flow Diagram
Records identification through databases PubMed, Google scholar and MEDLINE
(n= 873)
Records after duplicates were removed
(n= 438)
Records screened after inclusion-exclusion
(n= 87)
Records selected
(n= 7)
Records excluded
(n= 435)
Records excluded
(n= 348)
Records excluded
(n= 80)
Figure 1: Prisma Flow Diagram
(Source: Self-made)
5. Quality Appraisal
This paper used Caldwell critical appraisal tool in order to reflect upon the quality of the selected articles. It would be essential to understand that title of every article was descriptive enough to reflect upon its content. Further, authors of all the articles were credible except Kotlarczyk et al. (2017). Abstract of every article selected for the review provide appropriate summary of the key components included in the paper. Rationale for undertaking the research has been clearly outlined in every article except Stubbs et al. (2015) because it fails to specify the rationale behind research. Mackey et al. (2019) fails to provide up to date literature maybe due to lack of previously published articles. All the selected articles present clear aim for the research along with clearly addressed ethical issues.
Stubbs et al. (2015) and Mackey et al. (2019) did not provide adequate description of the samples selected for conducting their research. None of the papers provided variation for qualitative paper tool. All the papers presented enough description concerning major concepts of the study. Hewitt et al. (2018) failed to outline context of their study, which could make it difficult for the readers to decipher its exact objectives. All the selected papers described sampling methods. 
Mackey et al. (2019) mentioned that lack of prior published literature concerning ‘compliant flooring’ could have added bias to the paper. Likewise, use of standard fall and injury prevention interventions throughout study could also be the potential source of bias. Schulz et al. (2017) proposed that lack of prior published evidences for the long-term effectiveness of the fall prevention program could have added bias to the paper because of lack of comparison. Hewitt et al. (2018) did not reflect upon the age of their participants, which they considered as elderly.
Therefore, selection process here could have added to the biasness. Korall et al. (2015) mentioned the use of inclusion criteria for selection of articles; however, they did not reflect upon the specifications of their inclusion-exclusion criteria, which could again be considered as potential source of bias. Kotlarczyk et al. (2017) included participants especially women above 65 years of age. Therefore, the research data cannot be applied to other genders such as male because females suffer from higher levels of osteoporosis compared to males.
6. Summary and Synthesis of Papers
Article 1:
Falls are common among individuals; however, it could lead to serious injuries and even death among elderly individuals. Dhargave and Sendhilkumar (2016) mentioned that, a majority of elderly individuals tend to live alone or had to live alone,

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