PUTTING IT TOGETHER

i

DEVELOPMENT and EVALUATION of a NURSE PRACTITIONER–DIRECTED

INTENTIONAL ROUNDING STRATEGY, and its IMPACT on DECREASING FALLS in a

VETERANS LONG-TERM CARE FACILITY.

An Evidence-Based Scholarly Project

Submitted to the College of Health Professions and Natural Sciences

in Partial Fulfillment of the

Requirements for the Degree

Doctor of Nursing Practice

Fatima Bangura

Wilmington University

February 2024

ii

© 2024 Fatima Bangura

All Rights Reserved

iii

Wilmington University

College of Health Professions and Natural Sciences Doctor of Nursing Practice program

We hereby approve the Doctor of Nursing Practice project of

Fatima Bangura

Candidate for the degree of Doctor of Nursing Practice

Signature on File

_______________ __________________________________________ Date Pamela Jimenez, DNP, FNP/PNP-BC

DNP Project Advisor

Signature on File _______________ __________________________________________ Date Oluwatoyin Fajinmi Ed.D., MBA, MSN-RN

DNP Project Team Member

ACCEPTED

Signature on File _____________________________________ _______________ Aaron Sebach, PhD, DNP, MBA, AGACNP-BC, Date

FNP-BC, NP-C, CP-C, CEN, CPEN, CLNC, CGNC, CNE, CNEcl, SFHM, FRSPH

Dean, College of Health Professions and Natural Sciences

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Title: Development and Evaluation of a Nurse Practitioner – Directed Intentional Rounding

Strategy, and its Impact on Decreasing Falls in a Veterans Long-Term Care Facility.

Author: Fatima Bangura

DNP Project Advisor: Dr. Pamela Jimenez

DNP Project Team Member: Dr. Oluwatoyin Fajinmi

ABSTRACT

Background- Falls are a significant primary cause of accidental deaths and injuries among people

over 65 (Perng et al., 2019). Data from the World Health Organization (WHO, 2021) indicates

that falls are the second leading unintentional cause of death globally after road traffic injuries.

With a reported ten falls per month at the Philadelphia Veterans Affairs Community Living

Center, this DNP clinical practice change project sought to decrease the current fall rate below

the national rate of five falls per month or five percent per 1000 patient days. Method- consisted

of educating nursing staff of all levels assigned to the 25-bed unit of the veterans’ community

living center about the benefits and need of implementing intentional rounding. The

Intervention- sought to implement daily intentional rounding with the Morse fall assessment tool

on all patients ≥ 18 years over the 6-week period of the DNP project. Results indicated a

decreased fall rate below the national average during the period of the DNP project with an

increased rate with a return to non-structured rounding post intervention. Conclusion- pre- and

post-intervention data supported the use of intentional rounding with the Morse fall tool.

Keywords: falls, intentional rounding, hospital, inpatient, hourly rounding

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ACKNOWLEDGMENTS

I thank my Lord Almighty for making this journey and achievement possible. To my husband,

Nabie M. Bangura, a special thank you for your practical and emotional support as I added to the

roles of wife and mother, entrepreneur, worker, student, and community activities. I would also

like to thank our children, Maria, Martha, and Morlai Bangura, for their patience and

understanding. DNP would not be possible without their love, continued support, compassion,

and willingness to engage in this struggle. I want to dedicate this project to my husband, my

biggest cheerleader, and our three children. I want to thank my facility Associate chief nurse of

the geriatrics and extended care, community living center, and the staff members for allowing me

to work to improve our patient experience. Finally, I want to thank Wilmington University and

its many faculty members, especially Dr. Dawn Mutchko, my evidence-based instructor, and my

project advisor, Dr. Pamela Jimenez, who guided me through this experience. It is truly an honor,

and everyone is so appreciated.

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TABLE OF CONTENTS

ABSTRACT................................................................................................................................... iv

ACKNOWLEDGMENTS .............................................................................................................. v

LIST OF FIGURES ....................................................................................................................... ix

LIST OF TABLES .......................................................................................................................... x

ABBREVIATIONS ....................................................................................................................... xi

CHAPTER ONE: INTRODUCTION ............................................................................................. 1

Introduction ............................................................................................................................... ..1

Problem Description .................................................................................................................. 1

Rationale ..................................................................................................................................... 3

Theoretical Framework ............................................................................................................... 6

Specific Aims .............................................................................................................. ..………..8

Definition of Terms..................................................................................................................... 9

Chapter Summary ....................................................................................................................... 9

CHAPTER TWO: AVAILABLE KNOWLEDGE....................................................................... 10

Search Strategies ....................................................................................................................... 11

Intentional Rounding................................................................................................................. 11

Unstructured Rounding ………………………………………………………………………12

Staff Perceptions………………………………………………………………………..……..12

Cost Effectiveness………………………………………………………………..………… 14

EBP Model ................................................................................................................................ 15

Interventions on Decreasing Risks of Fall ................................................................................ 16

Chapter Summary ..................................................................................................................... 18

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CHAPTER THREE: METHODS ................................................................................................. 18

Context ...................................................................................................................................... 18

Interventions.............................................................................................................................. 20

Study of the Interventions ......................................................................................................... 21

Measures ................................................................................................................................... 21

Data Assessment ....................................................................................................................... 23

Analysis..................................................................................................................................... 23

Ethical Considerations .............................................................................................................. 24

Conclusion ................................................................................................................................ 25

CHAPTER 4: RESULTS .............................................................................................................. 26

Study group demographics ....................................................................................................... 26

Chapter Summary ..................................................................................................................... 30

CHAPTER 5: DISCUSSION AND IMPLICATIONS ................................................................. 30

Fall Reduction Trends ............................................................................................................... 31

Limitations ................................................................................................................................ 31

Implications for Advanced Nursing Practice ............................................................................ 32

Plan for Sustainability ............................................................................................................... 32

Application of the AACN DNP Essentials ............................................................................... 33

Conclusion ................................................................................................................................ 33

REFERENCES ............................................................................................................................. 34

APPENDICES .............................................................................................................................. 41

Appendix A: Search Schematic ................................................................................................ 42

viii

Appendix B: HSRC Final Application and Approval Letter .................................................... 43

Appendix C: CMCVAMC IRB Momo ..................................................................................... 44

Appendix D: CITI Training Certificate .................................................................................... 45

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LIST OF FIGURES

Figure 1: VA Projections for Long-Term Care Expenditures from 2017 to 2037.......................... 4

Figure 2: The Fundamentals of Care Framework: Relational, Integrative, and Contextual

Dimensions). ................................................................................................................................... 7

Figure 3: Morse Fall Scale (Kim et al., 2022). ............................................................................. 22

Figure 4: Patient Categorization by Age Group ........................................................................... 27

Figure 5: Patients’ Distribution by Gender ................................................................................... 27

Figure 6: Patient Distribution by Ethnicity ................................................................................... 27

Figure 7: Fall Rate for the Period Apr 2022-Sep 2023 ................................................................. 28

x

LIST OF TABLES

Table 1: Average Falls in Unit 1C .................................................................................... 28

Table 2: ANOVA Analysis of the Results ........................................................................ 29

Table 3: T-test Analysis Results ....................................................................................... 30

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ABBREVIATIONS

AACN- America Association of College of Nursing

CLC- Community Living Center

CITI- Collaborative Institutional Training Initiative

DNP – Doctor of Nursing Practice

EBP- Evidenced-Based Practice

HSRC- Human Subject Review Committee

IR- Intentional rounding

IT- Information Technology

LPN- Licensed practical nurse

NA- Nursing Assistant

PDSA – Plan, Do, Study, and Act

PICOT – Population, Intervention, Comparison, Outcome, and Time

PVMC- Philadelphia Veterans Medical Center

RN- Registered nurse

UR-Unstructured rounding

VA-Veterans affairs

WHO- World Health Organization

1

CHAPTER ONE:

INTRODUCTION

Problem Description

Falls are a significant primary cause of accidental deaths and injuries among people over

65 (Perng et al., 2019). Data from the World Health Organization (WHO, 2021) indicates that

falls are the second leading unintentional cause of death globally after road traffic injuries. Every

year, 684,000 people die from falls, with the elderly above 65 reporting the highest incidence

(WHO, 2021). According to WHO (2021), falls are defined as coming to rest on the ground, a

lower level, or a floor, excluding purposeful change in position to rest. Due to the high rate of

falls and the economic burden associated with falls, the WHO (2021) recommends investing in

strategies to reduce falls, especially in veterans who are at considerable risk due to

multimorbidity conditions with a goal of improving life outcomes (Christiansen et al.,2018).

The dynamic changes in healthcare settings have led to a need for healthcare

professionals to research new strategies and interventions to offer high-quality, evidence-based

healthcare (Di Massimo et al., 2022). The key concerns among this population included

decreasing the risk of falls and related injuries. A comparison of the veterans and the non-

veteran's fall risk showed that veterans were 1.25 times more likely to experience falls and fatal

injuries than non-veterans (Perng et al., 2019). In addition, the comparison among the individuals

diagnosed with mental illness and eye diseases revealed that veterans had a 1.36 more significant

risk of falls than nonveterans (Perng et al., 2019). Perng et al. (2019) attribute several risk

factors, such as complications and comorbidities, to the increased risk of falls among the elderly.

2

Medical centers and care facilities have taken significant measures to reduce the chances of falls

and injuries to the veteran population.

Due to the consequences resulting from falling, patients have adopted approaches such as

avoiding physical activity and day-to-day living activities. These approaches have an adverse

effect on health and quality of life. The focus of current systems on detecting failures has

emphasized prevention intervention instead of utilizing assessment scales that focus on the

condition, mobility, and fall history of patients. The focus on preventing falls was directed only

toward patient education, safety practices, and healthcare quality (Lipschuetz & Toren, (2019).

Although these efforts were vital, assessment only focused on safety should include a patient's

fall risks, hospital environmental hazards, and clinical conditions. According to Lyse Harden et

al. (2021), there is a significant need for interventions to prevent falls from focusing not only on

safety procedures but primarily on utilizing scales and measures that predict the causes of falls

and how best to avoid them.

There was a consensus that intentional rounding is one of the most effective interventions

in reducing the risk of falls and fall injuries among the elderly (Bayram et al., 2022; Lyse Harden

et al., 2021; Hamdan et al.,2022). Di Massimo et al. (2022) identify intentional rounding as a

favorable intervention leading to a low fall rate. East (2020) attribute purposeful rounding to

improved patient and nurse satisfaction. Rounding is systematic, proactive, and designed to

identify and address the needs of patients through a standard routine and protocol. This study

supported the effectiveness of rounding as a prevention intervention in preventing falls among

the elderly.

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However, existing literature reports that intentional rounding criticism increases

workload and limits the nurse's critical decision-making capacity as it makes the work routine

(Di Massimo et al., 2022). In the United States, the existing studies show fragmented results,

generalizing difficulty (Christiansen et al., 2018). There needs to be more research on its

application across different healthcare settings and information on its implementation methods

(Ryan et al., 2019). There is a comparison of the impacts of intentional and unstructured

rounding in a population of elderly veterans, which supports the need for robust research across

this field. Informed by this perspective, the DNP Project compared the impact of intentional and

unstructured rounding on falls in a long-term care facility for veterans within six weeks.

Rationale

This clinical practice change project aimed at improving the current fall rates at a local

veteran’s long-term community living center that averaged 10 falls/month on a 25-bed unit by

implementing structured intentional rounding using the Morse fall scale. Approved by the U.S.

Department of Health and Human Services, the Morse fall scale addresses six areas that increase

a patient’s fall risk and is noted to be the most straightforward predictor of a patient’s fall risk

(Jewell et al., 2020). The fall rate for 2022 provided by the facility Quality Management Team

used to track falls exceeded the national average of 5 falls per month in similar Veterans

facilities. Therefore, the aim of the project was to decrease the overall fall rate to keep it below

the national average. Additionally, the government and other stakeholders in veteran affairs have

invested significant resources into improvement strategies for those veterans in long-term care

4

facilities due to the increase in nursing home care which increased by 14% between 2014 to 2018

(Rasmussen & Farmer, (2022).

Moreover, the United States Government Accountability Office (2022) estimates the

projected expenditure associated with long-term veteran care to reach 14.3 billion dollars (about

$44 per person in the US) in 2037, as illustrated in Figure 1 below. The projections are in billions

of dollars for expenditure for long-term care programs.

Figure 1: VA Projections for Long-Term Care Expenditures from 2017 to 2037 (United States

Government Accountability Office, (2022)

The veteran demand for healthcare in long-term programs is projected to continue from

an increasing number of veterans and increasing access to non-veteran institutional programs.

Veterans have been eligible for long-term care programs since their establishment in 2002.

However, the program was suspended effective December 2022 for two years, subject to the

availability of funds and resources (United States Government Accountability Office, 2022).

5

As resources supporting veteran long-term healthcare continue to decline, the focus

remains on service-related disabilities. Limitations on funding to support veteran long-term

healthcare imply fewer resources are available for allocation to injuries related to falls and other

high-risk health problems experienced by the elderly.

A report by the Veteran Affairs Department acknowledges that falls present a significant

global health problem with high morbidity and mortality rates. In acute and rehabilitation care,

falls account for 30-50% of recorded injuries, with the cost per patient estimated at 3,500 dollars.

Annually, the cumulative cost of falls is 16,500 dollars, with falls with serious injuries increasing

the costs per patient to 27,500 dollars per year (United States Government Accountability Office,

2022). In 2013, the military required hospitals to assess the patient's risk of falls and implement

prevention measures in care plans. The assessment revealed that falls remain a significant

challenge in care facilities, underscoring the significance of prevention interventions that

promote patient safety.

Overall, falls and related injuries create a growing need to reduce costs associated with

veteran long-term care. Research supports a multidisciplinary approach as effective and reliable

for targeting at-risk populations such as the elderly. In addition to the impact on health, falls

could lead to lawsuits, reaching millions in settlement from injuries (Chu, 2017). The Veteran

National Center for Patient Safety identified prevention of falls and related injuries across

healthcare settings.

The department has enacted national guidance for decreased falls and injuries as crucial

in improving the quality of care among patients and personnel in long-term care (Severo et al.,

2018). Decreasing falls and related injuries complements existing veteran health affairs

programs. The VA department prioritized innovative clinical practices in reducing falls and fall-

6

related injuries (Bell, 2020). The goals and outcome-oriented plan suggested by the VA include

improving organizational capacity and infrastructure to prevent falls and ensure the safety of

environments.

Studies have shown that evidence-based education, assistive devices, optimal nutrition,

and effective mitigation policies lead to a strategic decline in falls. As falls pose a considerable

challenge in veterans' healthcare settings and huge expenditures, coordinated multidisciplinary

approaches are impactful in reducing fall incidences. Currently, systems implemented in

healthcare settings focus primarily on detecting falls with less emphasis on prevention (Heng et

al., 2020). Other interventions have focused on reducing the adverse effects of falls and

improving the quality of life for fall victims. Consequently, there was a huge need for developing

and promoting cost-effective approaches targeting the prevention of falls to reduce the

consequences and heavy financial burdens associated with falls. The DNP project was ideal for

comparing intentional and unstructured rounding to evaluate decreased falls in a veteran long-

term care facility.

Theoretical Framework

The foundation of care framework guided this DNP project. The framework provides

that nurses and healthcare providers develop positive relationships between providers and

patients as a pivotal contribution to improving patient satisfaction (Kitson et al., 2013). The

model acknowledges the significance of nurses balancing affordable and safe healthcare with

respect and protecting individual patient needs (Di Massimo et al., 2022).

The model identifies factors such as nursing skills, reform incentives for the health

sector, patient outcomes, and cost-effectiveness, which are vital factors influencing the need for

quality healthcare centered on the needs of patients. According to Kitson et al. (2013),

7

embedding patient voice across the health system and creating a caring environment for patients

and staff are critical principles that should guide a provider's work. The model recommends

redesigning the healthcare system to create a proper alignment between staff, patients,

organizational management, and regulators to address the flaws in the system.

The fundamental care framework has three dimensions, as shown in Figure 2 below.

They include relational, integrative, and contextual dimensions. The context of care is the outer

dimensions that involve the system and policy levels, such as resources, leadership, and

evaluation, finances, governance, and regulation. The middle dimension is integrative and

focuses on psychosocial contexts such as hope, respect, and dignity. The third dimension is the

relational dimension, which focuses on establishing a relationship between the care provider and

the patient (Kitson et al., 2013). The association is based on the commitment of the care provider

to communicate to the patient, family members, and other staff information about the patient to

ensure a consistent and patient-centered care approach.

Figure 2: The Fundamentals of Care Framework: Relational, Integrative, and Contextual

Dimensions (Kitson et al., 2013, p. 11).

8

The model provides a specific action plan for implementing the framework's core

elements for managers, clinicians, educators, researchers, and policymakers. Clinicians are

required to link key performance indicators to the fundamentals of care. Clinicians and managers

are also responsible for developing job descriptions and performance metrics to ensure the

foundation of care is within the specific nursing roles. Additionally, educators have a

responsibility to educate nurses to understand patient experiences and partnerships while

researchers have a role in developing approaches used to evaluate nurses' and patients'

experiences and tools to deliver fundamentals of care. Finally, policymakers have a role in

reviewing existing frameworks and facilitating standards, planning, and delivery of better

outcomes to patients.

Specific Aims

The DNP project aimed to compare the impact of intentional rounding (IR) and

unstructured rounding (UR) on the risk of falls in a long-term care facility. The project aimed to

reduce fall rates below the national average of 5 falls per month in similar VA facilities with the

desired expectation for the DNP project to compare the impact of rounding interventions

between intentional and unstructured rounding on the decrease in falls among veterans in a long-

term care facility. Purposeful rounding applies the 4P of pain, positioning, possessions, and

potty. The staff were educated on the benefits of intentional rounding using the Morse fall

assessment tool and the application of the 4Ps of intentional rounding to reduce falls. All nursing

staff (RN, LPN, and NA) assigned to the 25-bed unit received explicit training on scoring the

Morse fall tool. The PDSA cycle was utilized to assess the progress of the project and the need

for adjustment. The decrease in falls was the dependent variable, while intentional and

unstructured rounding were the independent variables.

9

PICOT Question

The PICOT question had a desired expectation for the DNP project to address: In

veterans residing in a long-term care community living center (P), how does intentional rounding

with the Morse Falls Tool (I) compared to the current practice of unstructured rounding(C) affect

falls(O) in a six-week period (T)?

Definition of Terms

• Intentional rounding - structured care rounds by nurses to patients to check their care needs

based on a specific protocol.

• Unstructured rounding - random or follow-up to check for patient care needs with no

specific protocol.

• Evidence-based practice - clinical practice integrating best research evidence and expertise

to inform clinical decision-making.

• Plan-Do-Study-Act (PDSA) - a tool or systematic process used to help implement a change

or improve a product, process, or service.

Chapter Summary

Chapter One introduces the problem of falls as a leading cause of death and related

injuries among elders over sixty-five. Veterans have a higher risk of falls than the general

population, significantly affecting their health and quality of life. The chapter introduced the

rationale for the study as increasing costs to long-term veteran care appear to arise in coming

years, with falls and related injuries accounting for a significant amount of the veteran healthcare

budget.

10

Therefore, it is substantial that preventions that promote patient safety reduce costs

associated with veteran healthcare. Next, the chapter introduced the research framework and the

PDSA process that guided the DNP project. Research consensus is that rounding is among the

most effective interventions in decreasing falls among the elderly. The study aims to reduce fall

rates below the national average of five falls per month or 5% in 1000-bed days in similar VA

facilities. It will also compare the impact of intentional rounding (IR) and unstructured rounding

(UR) on the risk of falls. Finally, the chapter defines the terms used in the DNP project. Chapter

2 will cover a detailed review and synthesis of the literature relevant to the DNP project.

CHAPTER TWO: AVAILABLE KNOWLEDGE

Search Strategies

The electronic database was carried out from Cumulative Index to Nursing and Allied

Health Literature (CINAHL), Medical Literature Analysis and Retrieval System Online

(MEDLINE), Academia Search Premier, and Nursing Academic databases. Search terms used

included intentional rounding, hourly rounding, purposeful rounding, falls, acute settings,

hospital, inpatient, and ward. The inclusion criteria considered full-text; peer-reviewed studies

published in English from 2018-2023. The focus was on the quality of the studies to ensure they

directly addressed the PICOT question comparing unstructured rounding in a long-term facility

to intentional rounding impact on falls in six weeks. The bibliographies for selected studies were

further reviewed for relevant resources to include in the study.

.

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Intentional Rounding

According to Lyse Harden et al. (2021), communication and hourly rounding positively

impact the risk of falls by 31% and falls with fatal injuries by 50%, while Gliner et al. (2022)

note that poor communication and lack of rounding increased fall risk by 8.6 times compared to

highly rated nurse communication (IRR =8.6, p <.01; CI 95%). Therefore, supporting the need

for Intentional Rounding as an effective intervention in reducing fall rates among the elderly

population. Another study lending support was carried out among military facilities where hourly

nurse rounding as an intervention reduced the fall rates by 21% (Gliner et al., 2022).

Additional studies by Tzeng et al. (2021) showed that tailoring interventions for patient

safety programs decreased the risk of falls and injuries by over 50 %. However, there is a notable

difference in the type of interventions addressing various populations to provide positive

outcomes in reducing the risk of falls and injuries among the elderly. Lyse Harden et al. (2021)

and Gliner et al. (2022) identify rounding as the most effective intervention in reducing the risk

of falls and related injuries. Hamdan et al. (2022) further acknowledge that hourly rounding is

among the most agreed interventions in preventing falls at a rate of 87.9%. Bayram et al. (2022)

also associate rounding with increased patient satisfaction and improved outcomes in quality of

care.

According to Sims et al., (2018), rounding is classified as intentional rounding (IR) or

unstructured rounding (UR). Intentional rounding is a structured process involving hourly checks

with patients based on a standard protocol (Sims et al.,2018. Pg 743). In the United States,

intentional rounding involves nurses carrying out one or two checks hourly through standardized

documentation and protocol. The standard protocol involves nurses identifying themselves to

build a rapport with the patient and carrying out standardized tests, including positioning,

12

personal needs assessment, pain evaluation, and placement (Sims et al., 2018). The Studer Group

developed intentional rounding as a proactive regular-based protocol for monitoring patients to

anticipate satisfying fundamental care needs and reducing adverse health outcomes (Di Massimo

et al., 2022). Additionally, intentional rounding protocol also involves assessing the

environment, such as checking for hazards and temperature. The rounding ends with

documentation of the nurses asking patients if they need anything and informing them when they

will return for the next round. Overall, Sims et al., (2018) reports intentional rounding has gained

significant interest in research in recent years and is influenced by the need to provide

compassionate, safe, patient-centered care. In return, there is a promotion of regular engagement

and interaction between patients and nurses.

Unstructured Rounding

Unstructured rounding is random and follows no specific protocol and varies in intensity

with less frequent rounding either on a daily or weekly basis (Bayram et al., 2022). Unlike

intentional rounding, unstructured rounding is historically carried out by care providers in the

wards without any guidelines by scientific basis and increases the risk or injury and or mortality

(Di Massimo et al., 2022). The DNP project compares the impact of intentional rounding to

unstructured rounding to decrease falls in a long-term care veteran facility.

Staffs Perceptions

Porter et al. (2018) completed a qualitative study design seeking to understand staff’s

perceptions of knowledge gaps between the implementation of a fall prevention program and the

sustainability of such programs. The study utilized a convenience sample approach with focus

groups and team member interviews by a trained researcher who specifically addressed the

team’s perspectives of fall protocols. 20 team members participated in the study with discussion

13

points surrounding the responsibility for falls. These topics included who might be responsible

for the falls, how did the falls occur, and knowledge of the importance of structured rounding.

Of those who participated, 15 were nurses, and 5 represented other clinicians. According to

Porter et al., (2018), two main themes surfaced. The first theme identified communication

related to the collection of information about the patients’ fall risk and how that information is

communicated among the team. The second theme related to the influences of the organizational

elements such as staffing, open doors to patient’s rooms, consideration for medication and

mobility devices that may affect a patient’s mobility or thought processes. Although the study

was only conducted at one organization, Porter et al., (2018) concluded that education of the staff

following careful assessment of perceived thoughts surrounding falls and intentional rounding

was imperative to the success of implemented structured protocols to decrease fall rates.

Another study addressing staff perceptions surrounding knowledge of fall prevention

strategies was conducted by Wilson et al. (2016) who completed a qualitative study over a

fourteen-month period in 13 acute care units of a large Veterans organization. The study sought

to evaluate nurses’ current intervention to prevent falls then circled back following the

implementation phase of intentional rounding to determine the impact a structured protocol had

on nursing practice and fall rates within each unit. The findings in this study provided insight

into nurses’ gaps of knowledge, satisfaction with a structured rounding protocol, and reinforced

the use of evidence-based strategies to mitigate risk based on patient tailored interventions

(Wilson et al., 2016).

14

Cost Effectiveness

Another aspect of intentional rounding deals with overall cost both for the patient and the

organization. A study by Spano-Szekely et al., (2019) evaluated fall rates and costs at a 245-bed

community hospital. Fall rates at this facility were 3.21 % higher than the national average and

costs for the organization due to prolonged hospital stays related to falls were noted to be close

to $84,000/year. Through the implementation of a structured intentional rounding policy, the

facility saw a marked decrease in falls to 1.14 % with a 72 % reduction in overall costs (Spano-

Szekely et al., 2019).

Benchmarks from the United Sates Department of Veterans Affairs, (2019), reported one

fall without serious injury costs a facility approximately $3,500 annually and those patients with

two or more falls without serious injury increased the annual cost to $16,500. For those patients

who suffered serious injuries due to falls, facilities often incurred additional costs of $27,000

annually. Although facilities implemented many strategies to decrease falls, those implementing

a structured intentional rounding protocol that provided adaptation to the type of patients served

was the most successful at keeping falls and costs below the national average (U.S. Department

of Veterans Affairs, 2019). With the dynamic changes in healthcare settings, there is a need for

healthcare professionals to research new strategies and interventions to offer high-quality,

evidence-based healthcare (Di Massimo et al., 2022). Therefore, a structured intentional

rounding protocol adapted to each facilities patient population meet the standards for high

quality practice and satisfies the mandates to improve care and cost among veterans and the

facilities in which they reside (U.S. Department of Veterans Affairs, 2023).

15

EBP Model

The study utilized the PDSA cycle and IOWA models. The selected EBP models have

consistently and uniformly guided nurses in practice settings. The IOWA model involves steps

that include issue identification, purpose statement, forming a team, synthesizing evidence,

designing practice change, integrating the change, and dissemination. The model is supported by

current studies as ideal for implementing research findings in practice settings and improving

patient outcomes (Cullen et al., 2022). The PDSA cycle (Plan, Do, Study, and Act) is a problem-

solving model used to improve a process or implement change in practice settings for over two

and a half decades (Katowa-Mukwato et al., 2021).

The model is comprised of an iterative process with planning as the first stage. This stage

involves assembling a problem and setting up a team and objectives. The first stage also includes

setting up an action plan, defining context and process steps, and identifying causes and

alternatives. The second stage is the do process. This stage comprises implementing the

developed action plan. The study stage is the evaluation process to identify improvement areas,

trends, and side effects. The last stage act involves reflecting on the plan and outcomes to

identify improvement areas with lessons learned (McNicholas et al., 2019). The PDSA model

can be used for implementation areas, including awareness of patient rights and responsibilities,

examining patient conditions, completing action plans, and holding multi-disciplinary meetings

regularly.

The PDSA process was selected as part of the EBP model for the current study as it

provides an excellent foundation for improving efficiency, reducing disparities, and improving

clinical outcomes. Comprehensive studies support the quality improvement model with

measurable improvements across healthcare settings, which is widely accepted in healthcare

16

(Katowa-Mukwato et al., 2021). The model is feasible and appropriate to guide the

implementation process for the intervention and assess any needs for adjustments. The IOWA

model is adaptable across healthcare settings as a framework for developing pilot projects in

clinical care (Iowa Model Collaborative, 2017). The IOWA model is problem-focused and ideal

for the current study in promoting evidence-based interventions to decrease falls for veterans in

an elderly care setting.

Studies reviewed acknowledge that falls are a key concern among the elderly population

aged above 65 years in long-term care facilities (Perng et al., 2019). For example, a comparison

by Perng et al. (2019) revealed that elderly veterans were 1.25 times more likely to experience

falls than non-veterans. In addition, data from the Veteran Affairs Department supports an

increase in fatal falls for veterans in long-term healthcare facilities by 14% in the four years

between 2014 and 2018, with the predicted associated cost of 14.3 billion dollars by 2037

(Rasmussen & Farmer, 2022; United States Government Accountability Office, 2022). These

studies reveal the increasing risk of falls and associated costs from fatal falls among the veteran

and elderly population as they justify the need for strategies and interventions to decrease fall

rates.

Interventions on Decreasing Risks of Fall

The review identified various interventions and strategies for preventing falls among the

elderly in long-term care facilities. However, limited studies focus on prevention strategies for

elderly veterans in long-term care facilities. This creates a gap in evidence-based strategies and

interventions targeted to the elderly veteran populations in long-term care settings (Di Massimo

et al., 2022).

17

One of the most effective interventions identified from the review is intentional rounding

in reducing the risks of fatal falls (Bayram et al., 2022; Lyse Harden et al., 2021; Hamdan et al.,

2022). The study by Christiansen et al. (2018) reported that intentional rounding reduced falls by

37% on average. Communication was identified as another effective intervention in decreasing

fall rates alongside hourly rounding (Lyse Harden et al., 2021). Lyse Harden’s study reported a

50% decrease in falls with fatal injuries and 31% in falls with light injuries.

Another study by Gliner et al. (2022) also noted that nursing rounding frequency and

nurse communication impacted the fall rate by 21% for hourly rounding compared to periodic

checks. In another study by Spano-Szekely et al. (2019), purposeful hourly rounding alongside

other interventions that include video monitoring and nurse-driven mobility led to a reduction in

falls by 54% with an equivalence of $84,000 annually savings in a 254-bed community hospital.

The findings by Bayram et al. (2022) support that intentional rounding increases patient

satisfaction. Therefore, rounding by nurse managers is crucial in supporting fall prevention

programs.

Other interventions are patient education attitude and compliance with IR protocols

significantly reduced falls. According to Heng et al. (2020), patient education in single and

multifactorial approaches decreases fall rates. Similarly, tailoring interventions for patient safety

also showed decreased injurious fall rates (Tzeng et al., 2021). Medication review also showed a

favorable impact on fall rates. According to a systematic review and meta-analysis by Ming et al.

(2021), the noted medication review positively reduces fall-related injuries.

A fundamental limitation among the review studies was the small sample sizes for most

of the studies.

18

However, the review's findings have significant applicability in the current project as

they support intentional rounding as an effective intervention in decreasing the risk of falls

among patients. In addition, the findings are evidence-based and establish a foundation for

implementing practice change with expectations for similar outcomes in the target population of

elderly veterans in long-term care facilities.

Chapter Summary

Chapter two introduces the search strategy implemented in the current study specifying

the search terms and exclusion/inclusion criteria. EBP models selected for the current study are

the IOWA and PDSA cycle models, which provide a framework for implementing intentional

rounding to reduce falls in elderly veterans' care home settings. Finally, chapter three will

provide a detailed analysis of the current study's context, interventions, measures, and ethical

considerations.

CHAPTER THREE:

METHODOLOGY

Context

Chapter 3 describes the DNP project's methods for reducing falls in long-term care

institutions for elderly veterans. This chapter discusses the project's study design, interventions,

measuring tools, data collection and analytic procedures, and ethics; hence, understanding the

project technique ensures the outcomes' integrity and reliability.

The project began by evaluating many contextual characteristics crucial to understanding

fall prevention strategies in long-term care facilities for elderly veterans. And the long-term

facility's characteristics were important contextual elements.

19

The project took place in a long-term facility for Veterans, the Philadelphia Veterans

Medical Center (PVMC), Community Living Center (CLC) over six weeks (June 8, 2023 -July

20, 2023). The PVMC has a 135-bed capacity with an average admission rate of approximately

one hundred Veterans, patients, or residents. This facility had four units or neighborhoods with

each unique specialty. These specialties were the short stay and rehab unit , the dementia unit, a

behavioral unit, and a ten-bed hospice unit. The project took place in the short stay and rehab

unit with a capacity of 25 beds and about eighteen to twenty veterans daily for the six-week

period.

The facility's elderly veterans’ demographics were also considered. For inclusion criteria,

all veterans admitted to the short-stay unit during the six-week period participated in this study.

This facility's demographic of sexes comprises over ninety-five percent males over females and

adults eighteen years and older. The population at the PVMC is unique in their military

experiences. A challenging history is significant mental health diagnoses like post-traumatic

stress disorder (PTSD), anxiety, depression, and bipolar. The facility's senior veterans' needs

were addressed by tailoring interventions to their unique fall risk factors. Material resources and

leadership support were available to assist with successful implementation.

Staffing and medical staff expertise were also included in the review. Participating staff

included about thirty nursing clinicians with different skill sets who participated in the

intentional rounding (RNS, LPNs, & NAs).

Staff competency and fall prevention techniques were assessed. If further training or

resources were needed, steps were taken to ensure personnel had the skills and support to

effectively implement the interventions (Aspinall et al., 2019). Facility policies, organizational

culture, and leadership support were also assessed.

20

Many factors can affect employee adoption and project success. Understanding and

accepting these contextual characteristics allows the therapies to be personalized and tailored to

the long-term institution which increases the therapies efficacy and longevity.

Interventions

The intervention sought to implement intentional rounding on all patients daily over the

6-week period of the DNP project of participants residing on the 25-bed unit who are ≥ 18 years

of age. Staff were educated on the benefits of intentional rounding using the Morse fall

assessment tool to reduce falls. The project coordinator provided the initial Morse assessment on

all patients meeting the inclusion criteria. Implementation of intentional rounding with a paper

version of the Morse fall tool began on the first day of the 6-week period for the DNP project by

the trained staff person of the day.

One of the four-point teammates observed intentional rounding techniques and was

responsible for collecting the Morse tool in a secure drawer in the supervisor’s office for the

project coordinator to review. The four-point teammates were a mix of two medical providers

and two rehabilitation workers. At the end of each week, the project coordinator collected the

forms from the locked drawer and reviewed the data with the Quality Management team dealing

with fall prevention.

The PDSA cycle was utilized to assess the progress of the project and the need for

adjustments. At the end of the 6 -weeks, data from the Morse fall tool was entered into an Excel

spreadsheet using an assigned participant’s number without identifying information. The

compiled data was quantitative data and compared the fall rates pre- and post-intervention to

determine if intentional rounding with the Morse fall tool reduced the monthly falls.

21

A comprehensive guideline was provided to improve the re-productibility of

interventions in comparable contexts and increase transferability. To achieve effective and

consistent interventions, the team collaborated to guarantee consistency, and the project 's

participant roles and tasks were clearly defined.

Study of the Interventions

The DNP project is ideal for comparing intentional and unstructured rounding to evaluate

decreased falls in a veteran long-term care facility. The established design made it easy to

quantify fall rates, allowing the project coordinator to examine the efficacy of interventions in

reducing falls among elderly veterans in long-term care institutions.

This project studied planned and unstructured rounding. Descriptive comparative

statistical analysis linked interventions to outcomes. Pre- and post-intervention assessments were

used to assess intervention effects. Pre- and post-intervention fall rates and outcomes were

measured (Harrison et al., 2019). This strategy helped identify confounding variables and

provide a benchmark for intervention efficacy. Comparing pre- and post-intervention fall rates

and outcome measures allowed the coordinator to attribute any differences to the therapies.

Measures

The project's measures were meant to reduce falls among long-term care veterans.

Interventions were evaluated using a variety of methods. It consisted of educating all nursing

staff (RN, LPN, and NA) assigned to the 25-bed unit of the Veterans Community Living Center

and the Morse fall assessment tool to reduce falls. The Morse Fall Scale tool assessed older

veterans' fall risk. Morse fall scale addresses six areas that increase a patient’s fall risk,noted to

have a high level of accuracy, and is noted to be the most straightforward predictor of a patient’s

fall risk (Jewel et al., 2020).

22

The Morse fall scale score was first published in 1989 with 0-125 scores (Kim et al.,

(2022). A meta-analysis of three studies in South Korea showed a sensitivity of 0.50-0.79 and a

specificity of 0.56-0.90 (Kim et al, (2022). Three studies conducted in other countries showed a

range of 0.74-0.91 and 0.54-0.73, respectively (Kim et al., (2022). A total measured score of <25

indicated a low risk, 25-50 indicated medium risk, and 51 or more showed a high risk (Kim et

al., 2022). The Morse fall scale tool did not require permission to use.

Figure 3: Morse Fall Scale (Kim et al., 2022).

Operational definitions accompany the selected measurements to assist in data collection

and interpretation. These definitions helped data collectors consistently apply and understand the

measurements, decreasing data collecting methodology disparities. Patient interviews and

observations assessed environmental factors in addition to fall risk (Wang et al., 2019). This

allowed the project coordinator to obtain quantitative data and compare the fall rates pre- and

post-intervention to determine if intentional rounding with the Morse fall tool reduced the

monthly falls.

23

The baseline or national benchmark is to have less than 5 falls a month.

The organizational culture involved some resistance to change from the frontline staff

and management. Navigating those challenges for the successful implementation of the project

took education, frequent reminders, and sharing best practice evidence. The facility was open to

the utilization of office spaces, overhead projectors, and laptops and allowed the staff to attend

project education sessions. The budget included stationery $100, postal $200, and printing $200

for a total of $500.

Data Assessment

Multiple methods were used to ensure data accuracy. Data collectors receive regular

training to ensure uniformity and accuracy. Standardized data collection and operational

definitions were stressed in the training (Edgar & Manz, 2019). The project coordinator checked

the data for flaws and discrepancies. The data was thoroughly checked for completeness, logic,

and accuracy. The data collectors were contacted to clarify any errors or contradictions.

Medical charts and facility databases were used to verify the acquired data and a daily

census was generated (Linares-Espinós et al., 2018). Additionally, each morse fall tool

assessment was matched to ensure completeness. These data assessment methods helped the

project coordinator improve data reliability and validity. The modification strengthened the

project outcomes and provided a solid foundation for data analysis.

Analysis

To conclude the project, a descriptive comparative analysis was completed. Descriptive

coding helped uncover and classify terms and patterns related to fall prevention and intervention

measures. This study discovered recurring themes and notable findings, which helped understand

senior veterans' and healthcare professionals' viewpoints. The areas of focus on the evaluation

24

tool were gender, age, race, secondary diagnoses, ambulatory aid, medications (2 or more), gait ,

and mental status, which were nominal and ordinal data.

Quantitative analysis analyzes and interprets numerical data from the investigation. The

mean and regression analysis were used to examine fall outcomes. These statistical tests helped

determine the importance of the variables' correlations, proving the interventions' fall-reduction

efficacy. The quantitative analysis provided a complete data view, enabling nuanced

interpretation. The quantitative studies also showed how these interventions affected fall rates

and consequences.

Ethical Considerations

The project was quality improvement (QI) in nature and was not subject to institutional

review board (IRB) oversight, but permission was obtained from the facility review board team

before the implementation of the project, (see Appendix C). The project also had to seek the

permission of the Wilmington University Human Subjects Review Committee (HSRC), (see

Appendix B). A training certificate was obtained from the CITI program on basic human

subject’s research, (see Appendix D). There was no funding source, and expenses were covered

by the project coordinator. Ethics were emphasized throughout the project to protect participants'

rights and well-being. An institutional review board (IRB) reviewed the project for ethical

compliance.

This project's ethical assessment protected participants' rights and well-being. The project

also followed informed consent standards to inform participants about the purpose, methods,

risks, and advantages of participating when required. Using unique identifications and securely

storing and processing data ensured participant anonymity and privacy.

25

Personal information was anonymized or removed to protect participant anonymity.

Upon completion of the project, the data was transferred to a bit-locker flash drive and will

remain locked in the management team drawer for three years. At the end of the three years, the

flash drive will be destroyed by the facility's Information Technology (IT) department.

There were no known conflicts of interest and the project coordinator disclosed any

potential conflicts of interest to reduce bias that could have affected the project. Additionally, the

project procedure and conclusions were protected against potential conflicts of interest.

Moreover, the project prioritized the subject of well-being and rights (Suri, 2020). A firm

commitment to ethics protected the project's ethical integrity and participants' well-being. These

ethical issues protected the project's integrity and results. It also highlighted participants' rights

and well-being.

Conclusion

Chapter 3 examined the DNP project's methods for reducing falls in senior veterans' long-

term care institutions. The chapter includes the initial consideration of contextual elements, a

detailed description of the interventions, the involvement of the project team, the project

approach used to evaluate the impact of the interventions, the selected measures for examining

processes and outcomes, the methods used for data assessment, the application of descriptive

comparative analysis, and ethical considerations.

The chapter emphasized long-term facility contextual characteristics and tailoring

remedies presented to the facility. Intentional rounding (IR) and unstructured rounding (UR) are

documented for replication. The pre-and post-intervention framework, statistical analysis, and

correction for confounding factors established a causal relationship between the interventions

and the observed effects.

26

The fall prevention project examined fall risk assessment methods' efficacy. Contextual

elements were assessed to evaluate the interventions' impact and ensure data accuracy by using

validation tools. The project data was quantitative using nominal and ordinal coding. Ethical

considerations were kept at the forefront with informed consent, confidentiality, managing

conflicts of interest, and prioritizing participant welfare and rights. This chapter laid the

groundwork for the DNP project's legitimacy, consistency, and ethical consideration.

CHAPTER FOUR:

RESULTS

The fourth chapter represents the results of the DNP project that aimed at comparing the

impact of intentional rounding (IR) and unstructured rounding (UR) on the risks of falls in the

long-term care facility. The project aimed to reduce fall rates below the national average of five

falls per month or five percent per 1000 bed days in similar VA facilities. Using descriptive

statistics, the dependent variables encompass reducing the falls, while the independent variable

includes the intentional and unstructured rounding. The study focused on veterans aged 60 years

and above with most between 71-75 years who resided in the long-term care community living

center.

The sample consisted of an average of 20 participants daily; however, participants completed the

study at different times during the six-week period due to the time of admission to the facility.

27

Figure 4: Patient Categorization by Age Group

Figure 5: Patient Categorization by Gender Distribution

97 % of the patients considered in the study were men.

Figure 6: Patient Distribution by Ethnicity

28

Most of the study population were whites, followed by Blacks, and to a lesser degree

Hispanics. The project unit-1C experienced a significant fall rise in two consecutive months

(April 2023, 8.9%, and May 2023, 6.6%) before the start of this study. The study started in June

and ended in July 2023, with fall rate percentages of 4.5% per 1000 bed days in June and 1.37%

per fall in 1000 bed days in July. The unit fall rates two months after the project completion

elevated to a 6.38 % fall rate in August 2023 and an 8.21 % in September 2023. One reason for

the increase in falls could relate to the staff’s return to unstructured rounding.

Figure 7: Fall Rate for the Period Apr 2022-Sep 2023

Data displayed in the graph above indicates the number of falls based on unit 1C, and the

trend pre- and post-implementation of the project. During the project period June-July 2023, data

clearly demonstrates how intentional rounding effectively decreased fall rates while the months

prior and after demonstrated increased falls. Therefore, supporting the use of intentional

rounding. However, the ANOVA and T-test analysis failed to provide a significant difference in

rates when comparing previous years without intentional rounding.

29

Many variables may factor into this analysis with the most obvious reasons relating to the

limited time of the implementation and the small sample size.

Table 1:

Average Falls in Unit 1C over three years

Time period Unit 1C average falls

2021 3.81%

2022 2.34%

2023 (except June and

July) (pre-implementation)

5.03%

2023 (June and July)

post-implementation

2.95%

Table 2:

ANOVA Analysis of the Results

F-stat P-value

1.211 0.324

From this data, there was no significant difference between falls for unit 1C between the

implementation period and the pre-implementation period.

30

Table 3:

T-test Analysis Results

T-stat P-value

0.790 0.456

From this data comparing T-stat and p-value, we can say that there was no statistically

significant difference between the falls for 1C.

Chapter Summary

Chapter four of the study introduced the results section. The falling rate trend among the

studied population was identified with the probable factors explaining the trend. The study

identified the healthcare workers and management's commitment to ensuring patient safety as the

fundamental factors in reducing falls among the elderly in the healthcare facility. Although the

number of falls was reduced from the ANOVA analysis and the T-test, it was clear that the

decrease in the number of falls was not statistically significant. The next chapter will discuss the

results in detail while supporting other secondary sources.

CHAPTER FIVE:

DISCUSSION AND IMPLICATIONS

Chapter five of the study discusses the results of the DNP project and their implication

for clinical practice and future research. The discussion substantiates the reasons behind the use

of the declining fall rate over the time frame.

31

Fall Reduction Trends

The study recorded a significant reduction in the fall trends during the implementation

period. The declining trend aligned with the project goal of reducing the fall rates below the

national average. The declining fall trend was associated with different factors, including staff

engagement, management support, patient safety, and early detection of patient condition

changes. The staff’s engagement was a contributing factor to the declining fall prevalence. This

indicates that the healthcare workers were actively participating in implementing the intervention

to reduce falls and improve patient safety. Additionally, management support marked with the

resource allocation to the fall prevention initiatives also promoted success in the fall prevention

(Thomas et al., 2019).

Patient safety is a primary goal of the healthcare facility, and therefore, the reduction in

the fall rate indicates that the management is taking the lead initiatives to prevent injuries and

incidents related to falls in the respective units. The early detection of patient condition changes

is also key, enabling prompt intervention and improved patient outcomes. Ren & Peng (2019)

noted that using fall prevention technologies after early detection has reduced the number of falls

in healthcare facilities.

Limitations

The study's major limitations included time constraints, smaller sample sizes, and

inconsistencies in Morse fall rating scores. The study conducted over six weeks provided a short

period which could have failed to capture long-term trends or variations in the fall rates among

the elderly. The seasonal changes in health conditions can also influence falls over time. The

second limitation is the small sample size and the limit to one unit in the facility, which limits the

generalization of the study findings.

32

The small sample size may not represent the broader elderly population. However, having

the ability to increase the sample size would enhance research reliability. Another challenge was

the inconsistencies in Morse fall rating scores arising from inter-rater variability and

misinterpreting the assessment tool. Teaching was adjusted to rectify this finding.

Implications for Advanced Nursing Practice

The implication for nursing practice includes improving the current fall rates by

continuing with intentional rounding and expanding the project to other units. The results of the

study are effective in adopting viable and best strategies for preventing falls and the impact

among the elderly. The study also effectively utilizes a validated tool and enhances practices to

reduce fall rates. The study was paramount in improving the current unstructured intentional

rounding practice and tracking outcomes. Fall reduction is an ongoing process that needs

consistent effort and focus; therefore, the study helped to strategize the effective means of

maintaining the processes of fall prevention for the elderly.

Plan for Sustainability

The committee members can act as ambassadors and share the monthly fall rates among

the staff to reduce future falls. There is also a need to attend staff meetings and remind the staff

about fall prevention and participation in fall huddles. Monitoring and supervision from the

management are also needed to set a sustainable fall prevention plan for the elderly. Continued

membership at fall committee meetings during the implementation phase provided an

opportunity for shared practices that assisted in the decreased fall rates during June and July

2023.

33

Application of the AACN DNP Essentials

Essential I: Scientific underpinnings for practice: Use scientific evidence to inform fall

prevention strategies and interventions like improving management and patient safety.

Essential II: Organizational and system leadership: Leading and advocating for fall

prevention initiatives within the healthcare organization.

Essential III: Clinical scholarship and an analytical method for evidence-based practice:

Conduct study and analysis to evaluate the effectiveness of the existing and proposed fall

prevention program.

Essential IV: Information system/technology and patient care technology for improving

and transforming health care: Leverage technology to promote fall risk assessment and early

detection and response monitoring.

Conclusion

Fall prevention among the elderly is a crucial spec of healthcare given the impact of the

fall on the targeted population. Though the study has limitations and challenges, the advanced

nursing practice guided by AACN DNP essentials made the study fundamental in preventing and

mitigating fall risks. To promote long-term success, sustainability efforts are desired through

ongoing assessment, education, and community engagement. Integration of the technology and

dedication of the nurses in the advanced practice is also paramount in promoting the elderly

well-being as far as fall is concerned.

34

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APPENDICES

Title of Appendix

The following items are required but not exclusive:

Search Schematic

HSRC Final Application and Approval Letter

CMCVAMC IRB memo

CITI training certificate

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Appendix A: Search Schematic

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Appendix B:HSRC Final Application and Approval Letter

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Appendix C: CMCVAMC IRB Momo

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Appendix D: CITI Training Certificate

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