NURS 8211C

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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

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© 2024 Fatima Bangura

All Rights Reserved

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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

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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

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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

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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.

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