Capstone Project Change Proposal

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Jane Student

Grand Canyon University

NRS-465: Applied Evidence-Based Project and Practicum

Professor Leslie Greenberg

January X, 2024

Capstone Project Change Proposal

Anyone who has ever been in an inpatient facility or worked at one is aware of the impact

falls can have. Falls have been and remain one of the most frequent, debilitating, and costly

problems at an inpatient facility. The patient will have a now indeterminant hospital stay, and the

providers and staff question what could have been done differently to prevent falls from

occurring. From leadership to the shareholders’ standpoint, finding a cost-efficient elimination in

inpatient falls has been problematic. Below will be discussed the background and the clinical

problem, purpose of the interventions, the PICOT question that was used for this implementation

project, literature search strategy, literature review, nursing theory, implementation plan with the

potential solutions and outcomes measured, and plan for evaluating the nursing intervention and

barriers and how they may be overcome. The proposed interventions are to eradicate further

patient injuries, mistrust in the community, staff burnout, and potential cost to organizations and

shareholders.

Background of Clinical Problem

Inpatient falls in a hospital setting is not only an organizational issue but a community

issue as well, and it is causing a significant burden not only to the healthcare system, but

families, patients, and the communities in which the hospital serves. Falls lead to increased

hospital stays and more testing to make sure the patient did not suffer an acute injury. The Center

for Disease Control and Prevention conducted a study and reported that the costs for falls were

about $50 billion annually and this is expected to rise to $100 billion annually by the year 2030

(Luebbert, 2022) due to the Baby Boomer Generations’ retirement.

However, on the patient side, a fall can lead to a devastating disability or even death. It is

the hospital's job to keep patients safe, and this is failing, shown by the numbers of falls

increasing nationwide and the amount of money spent every year. There are many reasons why

there may be an inpatient fall, but it is dire that other interventions are introduced to predict and

prevent falls. The project change proposal that is being introduced is the Get Up and Go Test and

patient and family fall prevention and education to be used as a multimodal way of combating

adult falls in an inpatient setting (Leubbert, 2022).

Clinical Problem Statement

During an average hospital stay, adult patients or post-operative patients often have

decreased mobility since they are confined to their beds. They may get up with physical therapy,

an aide, or a nurse, but it is often limited and leads to decreased mobility. There could be other

reasons, such as medications, weakness, visual disturbance, and orientation levels. However,

many times, a patient is put on the bedpan instead of offering them the option to get out of bed

and use the bathroom with assistance, or the patient simply does not want to keep bothering the

staff.

Falls are considered “Never Events” in all healthcare institutions, and this places an

exuberant amount of pressure on nurses and staff. This can cause the nursing staff to develop a

fear of a patient falling which may restrict patients, especially high-risk patients, from mobilizing

in their room (Agency for Healthcare Research and Quality, 2019). These types of measures do

not bide well with the patients, providers, or the administration. The impact on the patients is

multilayer as it causes physical and psychological damage. As far as the hospital staff, it can

cause increased stress and increased turnover rates (Agency for Healthcare Research and

Quality, 2019).

Falls are not limited to just the United States, this is a global problem and encompasses

all inpatient settings. Globally the fall rate is from three to eleven per one thousand beds (Heng et

al., 2022). In the United States, Medicare and Medicaid will no longer pay the organizations for

falls since it is considered a preventable injury which leads to an organization losing revenue

(Zhoa et al., 2019). Not only does this financially impact the organizations but it impacts the

trust within their community, is often devastating for patients and families, and increases the cost

of health care benefits which affects everyone.

The Acute Care Hospital of the XX is one of the oldest hospitals in the nation. Patient

care has always been their top priority, and their mission statement revolves around providing

progressive health care services, providing an enriching employee experience, and delivering

exceptional patient experiences

During the present fiscal year, two medical-surgical units at XX Hospital had an increase

in falls. In March and April of this year, there were sixteen falls (Appendix B). Their falls

interventions currently are hourly rounding, fall prevention signs, yellow socks, Morse Fall

Predictor tests for every admission, TIPS boards (Appendix C), one to one observation, and bed

alarms. This organization's main priority is to make a patient's hospital stay safe while providing

the best patient experience, so this is a major concern for the organization as well as the leaders

of this establishment, in which they hope to find an answer soon.

Change Proposal

The change proposal will help reduce adult inpatient falls in a hospital. Adult inpatient

falls are an ongoing problem not solved since the start of inpatient care. While there have been

protocols and policies to help reduce the number of falls, it is still a global problem that not only

causes harm to patient and families, but trickles downward to increase staff stress, increase

mistrust in the community, and is financially burdensome to the healthcare organizations and

their stakeholders.

Research has shown that using the Timed Get Up and Go Test or TUG, is a quality

indicator of a patient's baseline balance and mobility. The new intervention's purpose would be

to use the TUG test for every new admission or for a post-operative patient who has orders to get

out of bed within six hours upon arrival on the floor. The TUG test would give nursing the

advantage of a reliable predictor and evaluator of a high risk fall patient. This test has been

widely used in elderly patients in the outpatient world. TUG testing evaluates standing, walking,

turning around, and sitting down. This allows the primary care team to access a patient's balance

and baseline mobility and gait, which helps evaluate their risk for falls in the home (Ziegel et al.,

2020). There are a few simple instructions in the TUG test. First, the patient sits in a chair,

expected to stand, walk to a line about nine feet away, turn around, walk back to the chair, and

sit back down (Appendix D). This should take about ten seconds or less, but the time will be

elevated up to two minutes if there is balance or mobility issue with the patient (Caronne et al.,

2019). This will give staff a better indicator of equipment needed, if the patient is at a high risk

for falls, and place high risk protocols for the patient.

Research and evidence have shown that patient and family education on falls as the only

intervention has shown a decrease in falls (Zhoa et al., 2019). Fall education should be done in

multiple ways because each patient has a different learning style. Face to face education,

brochures, pamphlets, educational handouts, and videos should all be part of the fall's education

and prevention program (Heng et al., 2022) which will reach every learning style. The written

educational literature should be readable at a fifth or sixth grade level and exclude medical

jargon. These will need to be readily available in all languages and easy for staff to access. This

will help the patient and family see the importance of fall prevention in the hospital and how

devastating an impact it can be.

PICOT Question

The PICOT question is a useful and beneficial approach for outlining a research question,

which allows for more refined research for the proposal. The P refers to the population or the

subject that will be involved in the research. The I refers to the intervention that will be

researched. The C is the comparison by using a reference group to compare outcomes. The O is

the outcome, which examines the effectiveness of the proposed intervention. And lastly, the T is

the time used for the data collection’s duration.

The Capstone Project PICOT question for reducing hospital falls would be: With

hospitalized adults, (P) can the combination of falls prevention education and the Get Up and Go

Test, (I) compared to the current falls interventions, (C) reduce inpatient falls (O) in a six-month

period (T)?

Literature Search Strategy

A literature search strategy is important when starting a new research project. The Grand

Canyon University Nursing and Health Sciences Research Guide is a vast and comprehensive

research database (Grand Canyon University, n.d.). This database offers up-to-date eBooks,

journals, peer reviewed articles, evidence-based data and other materials often used for research

from reliable sources. This allows researchers to find the necessary evidence to support their

project. This vast database includes PubMed and CINAHL.

Using key words to refine the search for proper research journals will help find the

appropriate articles needed. For example, using the key words while searching adult inpatient

falls would be adult inpatient falls, patient falls education, Get Up and Go Test, and falls

prevention in an inpatient setting. Research has found that the information students gather while

completing their Capstone Project replicates and demonstrates best practice (Landfried, 2023).

Synthesis of Literature Review

A literature review allows a researcher to interpret and integrate findings from multiple

sources and perspectives. Literature reviews often support the research questions being

researched and evaluated and the review articles are an important part of the scientific research.

This allows the researchers to understand prior work already done and can look for holes in the

research that may need further review (Kraus et al., 2022).

The falls prevention and intervention research that was done has shown similar outcomes.

According to Zhoa et al., (2019) evidence shows that patient education as the only intervention

has shown to decrease falls but the development of multicomponent fall prevention strategies

including patient education will decrease inpatient falls substantially. According to Heng et al.,

(2022) education should be given not only by face-to-face interaction but also by educational

handouts, brochures, and videos. This should be done in multiple languages, excluding medical

jargon, and should be presented at a fifth or sixth grade reading level. This study conducted a

scoping review of current research to identify gaps and focused its aim of patient education and

to identify variables used to changes in falls.

The qualitative study from Dabkowski et al., (2022) believes that to help prevent falls a

nurse needs to know a patient's perception of their fall risk. This research interviewed eighteen

individuals, with whom sixty seven percent had a fall within the last six months, but the patients

did not consider themselves a high fall risk. The article of Heikkila et al., (2023) states that the

health care staff needs to know the increased risks factors for falls. This research used electronic

health records from 2014-2016 in a large university hospital and using a regression model

analysis identified risk factors for falls. The research article from Gilner et al., (2022) shows that

increase of communication between the nurse and the patient could decrease falls. This used the

Joint Patient Safety Reporting system from 2017-2019 with a satisfaction survey included. This

data showed that the better the communication between nurse and patient decreased falls by a

twenty one percent reduction rate.

Two of the articles studied the Get Up and Go Test. Ziegle et al. (2020) stated that this

test was a better predictor of substantial risk fall patients. It showed that the TUG test using two

different regression and probability models there was a significant difference in the TUG test

between fallers and non-fallers. The Caroni et al., (2019) study, using one hundred and twenty

patients at a rehabilitation center, showed that the Get Up and Go test is a good indicator of

baseline mobility and balance, and that after physical therapy the patients TUG test improved.

Montero-Odasso et al., (2022) found that tailored interventions and education help reduce the

risk of falls.

Out of all eight studies, three themes emerged. Firstly, the Get Up and Go test is a good

indicator in its ability to assess baseline mobility and balance issues in a high-risk population.

Nursing education to patients about fall risks and preventions should include one-to-one

conversations, pamphlets, brochures, and videos, and can help with a reduction in falls.

However, another theme, which one I did not expect, emerged in these studies, not one fall

intervention alone can prevent falls, it must be multimodal and tailored for individual patient

needs.

Nursing Theory

Using evidence-based practice often goes hand in hand with nursing theories and is

important in any research that is implementing a change in practice. For prevention of adult falls

in a hospital two theories immediately come to mind.

Joanne Duffy’s Quality-Caring Model. This theory was chosen because it focuses on the

relationships between the patient and the provider, colleagues, self, and community. This helps

create an environment of collaboration and respect, and is patient centered. It involves caring

behaviors including mutual problem solving, respect, encouragement, healing environment,

support of each other and other interdisciplinary teams, and addressing psychological needs of a

patient including safety (Salina et al., 2022).

Kurt Lewin’s Change Theory is a model about stages of change. The first stage is

regarded as unfreezing, which is where groups let go of old behaviors or habits. The second stage

is the change itself, and the third stage is the refreezing of the new behavior. The final stage is

the establishment of the new habit (Burns, 2020).

For the Capstone project of decreasing adult falls in an inpatient setting the Change

Theory is the better theory to be incorporated into the change proposal due to getting rid of old

habits and incorporating new habits.

Implementation Plan

To start any project a plan needs to be discussed. The discussion of the project would be

proposed to leadership. Managers, directors, educators, and internal stakeholders would need to

be involved with implementing falls prevention. This would entail multiple meetings with each

using evidence-based research, both quantitative, qualitive, and mixed method research designs

(Cassidy et al., 2021), and incorporate it into the presentations. The need for interdisciplinary

collaboration is important at this time so the educators can start working on the clinical

competencies (Gcawu & van Rooyan, 2022) and the nursing leadership to work on policies. The

first step would be directed to managers to garner their support for the project. The second step

of the proposed changes would be discussed with the directors. Once that is approved, the project

would then be presented to the educators including draft proposals of various power point

presentations, videos, and pamphlets for their input and approval. Once approved by the

directors, the project in its final form would be presented to the internal stakeholders, external

stakeholders, and any other individuals involved with funding. This would be accompanied by

the costs projected for each step of implementation.

The collaboration with nurse educators on the best way to deliver staff education and

clinical teaching is extremely important in the development of the clinical competencies (Gcawu

& van Rooyan, 2022) of the Get Up and Go test. This would entail setting up time to draft and

finalize educational pamphlets, brochures, and videos for patients. All falls prevention brochures,

pamphlets, and videos should be in multiple languages, exclude medical jargon, and be presented

at an appropriate reading level, preferably the fifth or sixth grade. There would also be

discussions on Get Up and Go training regarding timing and location. Super users should be

considered for the training aspect; however, it would have to be approved by internal

stakeholders, owners, and any other individuals involved with the funding for training.

The next step would be coordination with nurse educators about documentation aspects in

the Electronic Health Record for a straightforward way for the staff to document the Get Up and

Go test. Documentation of the fall's prevention education must be discussed with involved staff

so it can become part of the nurse care plan with a flawless transition from the flowsheet to the

patients care plan. Education for this will be through “Knowledge Link” further discussed below.

The education plan for staff to learn the Get Up and Go test and patient falls education

would begin online with a course added to their “Knowledge Link,” the video learning system

that this organization uses. This on-line education would entail a learning module video and a

test regarding both the Get Up and Go test and patient education. This can be done at the hospital

during working hours if there is no disruption in patient care. The “Knowledge Link” course

would have to be completed before the hands-on training.

There would also be quick instructions on how to translate written literature on fall

education in multiple languages. XX Hospital utilizes a “Tip sheet” about instructions on how to

translate the education packet for patients to other languages so it can be easily accessed.

The next step would be a learning session. Time for educating and instructing nursing

staff will have to be set aside without disruption to the hospital patients. There is another option,

if approved by the internal stakeholders, owners and any other individuals involved with

funding, the training which could be held outside working hours with pay.

The last discussion should be scheduling of a location for the training. The XX

auditorium inside XX Hospital can hold up to 100 people and has space to practice. This

education would start with an interactive power point with questions at the end. From there, staff

will be provided with space to see a demonstration of the Get Up and Go test. At that point, each

person should demonstrate the Get Up and Go Test, evaluated by either a super user or a nurse

educator, upon passing staff would then be signed off. This education and demonstration would

have to be done every year on the “Knowledge Link” system and at the skills fair as there may

be modifications to the test.

For six months there would be designated super users for the Get Up and GO test and

patient education to help nurses and staff with starting these new processes providing nurse

leaders approval.

Evaluation Phase

Evaluating the reduction of adult inpatient falls would be to use a measurable outcome

(Appendix A). The measurable outcome of the proposed intervention is reducing falls within six

months of the implementation. The goal is to have 1 fall in one month with the hope of zero or a

twenty five percent reduction of falls in six months. This data will be collected by the Falls

Prevention Safety Meeting and will be given to the data analysis point person. Once the data is

collected and interpreted this will be graphed and given to the Falls Prevention Safety team to

review and see if the new interventions of falls are reducing incidences of falls.

There will be a survey (Appendix E) that is given to the patient at the end of their stay

regarding if the falls prevention education was understood and if it was a consistent dialogue

between staff, patient, and families throughout their hospital stay. This is also done with their

stroke patients and has proved to work on patients stroke education, this is to be given to the

nurse manager upon completion and at the patient's discharge.

All staff, by the end of the six months, would be one hundred percent signed off on the

“Knowledge Link Modules and Get Up and Go training. This will be part of a yearly training

course with the staff competencies and at the Skills Fair.

Lastly, through mandatory surveys and open forum discussions, feedback will be

evaluated from the staff to assess any problems, concerns, ease of documentation, and the

effectiveness of the interventions. This will be an opportunity for staff to express concerns and to

give advice to each other.

Barriers

With any new project there are concerns about barriers. The barriers that are foreseen

would be lack of resources and staff engagement.

Staff engagement is always a challenge for recent changes. The nurse leaders should offer

support and ask for feedback if staff have any concerns regarding the new interventions. Having

staff engaged and adding their thoughts may work better leading to a stronger and satisfied staff,

with better outcomes for patients (George & Massey, 2020).

Lack of resources would be another barrier to implementing a new project as revenue can

be unpredictable (Lagasse, 2019), and the loss of revenue would stop the implementation of an

evidence-based project in its tracks. But this can be solved by external stakeholders financing

this project. For example, the cost of the above implementation project would cost an estimated

$40,000 in six months. This estimated cost involves nurses hourly rage times the number of

nurses the unit has. Since most of the “Knowledge Link” module can be done during work time,

there would be no extra cost. Nurse educators work five days a week on site, so this also would

save on costs. The Zubrow auditorium is also on site so again there would be no additional cost

and that will also help with budgeting. The brochures, videos, and written materials would not be

much of a cost and are estimated at $5000.00 for the first six months as this organization is self-

sufficient in this area and does not need to outsource.

Conclusion

Adult inpatient falls have been and remain one of the most problematic situations in the

hospital. Falls cause financial problems to hospitals and can cause debilitating injuries and death

to the patients. Community trust can be broken, and stakeholder involvement can decrease

because of increased falls. The hope of adding the Get Up and Go Test and patient falls

education will decrease the incidence of falls two units at XX Hospital within six months. If this

works as projected and there is substantial evidence in the implementation of these two

interventions, then it will be taught throughout the entire hospital. Again, if the evidence shows

progress, it will move up to the other entities of the XX Hospital and their satellites, reducing the

number of inpatient falls throughout the healthcare system.

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Corbo, M. (2019). How do patients improve their timed up and go test? Responsiveness

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NRS-465: Capstone Change Project Evaluation Plan

Instructions: Complete the table and questions that follow to develop an evaluation plan for your

proposed project. Use the Topic 5 Implementation Plan assignment and associated faculty

feedback as a starting point. Students will have 3-5 objective (goal) and outcome pairs for which

an evaluation plan will be developed.

Part I: Evaluation Plan

Project Objective (Goal):

 1. Decrease adult inpatient falls in a hospital.

 2.Increased awareness and education of falls for patients and families.

 3.Competence in the Get Up and Go Test

 4. Increased staff competency in educating patients and families on the fall's prevention

programs.

Measurable Project Outcome:

 Decreased falls on 7 Cathcart and 7 Preston within a 6-month period.

 Patients and families will be more educated on the risk of falling and the harm it can

cause while in the hospital.

 100% competency within 6 months for all staff.

 100% completion of Knowledge Link courses on patients fall education learning course

within 6 months,

What data will be collected to measure this outcome?

 Managers from every floor every day discuss falls within 24 hours, this then goes onto

the Falls committee, data analysis (Mike), falls safety team committee. Data Analysis

(Mike) is also on this safety team so the data will be recorded.

 Surveys will be conducted to patients at the end of their hospital stay about understanding

the risk of falls.

 Educator/Manager sign off on education

 Knowledge Link education system test on falls and patient education

What tool will be used to collect the data?

 Falls safety team committee. Data Analysis (Mike) is also on this safety team so the data

will be recorded.

 Patient surveys that will be given at the end of their stay regarding how much was

understood of the falls education and was the education a continuous dialogue between

staff and patient

 Knowledge Link education system

Who will be responsible for collecting data?

 Data analysis (Mike)

 The survey will be given to the nurse manager at the end of the patient's stay.

 Nurse Educator oversees all the competencies

Part II: Communication Plan

How will the data collected be communicated to the team?

Every day there is a falls safety team and prevention task force that meet with the nurse

managers and assistant nurse managers. The data analysis team is also included along with the

quality and safety team and the informatics team. All falls are discussed every day. These teams

meet every day even when there are no falls, and the data analysis team goes over statistics of

how the hospital is doing over all with managing their falls. After the discussion with these

teams' managers and educators then discuss this with staff at the interdisciplinary rounds where

nurse practitioners, physicians' assistants, and social work are coordinating care with staff. This

is also an everyday meeting that will continue to be every day.

APPENDIX B: Falls Data from XX Hospital

APPENDIX C: Falls Data from XX Hospital

APPENDIX D:

Tips Board at XX Hospital

APPENDIX E

TIMED GET UP AND GO TEST

Appendix F: PATIENT SURVEY ON FALLS EDUCATION

1. Did hospital staff educate you on fall preventions while in the hospital?

YES NO

2. Were you given time to ask questions about the fall's prevention program while in

the hospital?

YES NO

3. Were you educated throughout your stay about the fall prevention program by

different staff members?

YES NO

4. Were you given face to face education by the hospital staff on the fall's prevention

program?

YES NO

5. Were you given handouts, brochures, and videos on the fall’s prevention program

while you were in the hospital?

YES NO

6. Did you feel comfortable upon discharge on falls prevention even when you are at

home?

YES NO