Nurses play an essential role in the rehabilitation process, enhancing people’s quality of life and independence following an injury, sickness, or chronic illness. The practice of rehabilitative nursing incorporates certain distinctive aspects of the function of a nurse in the context of not just routine but also multidisciplinary and interdepartmental work. Stroke, acquired traumatic brain injury, spinal injury, orthopedic rehabilitation, and chronic illness management are the most common and vital practice areas to work within this field. Care for older persons is also an important aspect of the experience. Specializing in assisting individuals with disabilities and chronic diseases to attain maximum functioning and health and adapt to changing lifestyles requires continual interaction with some of the challenges that need to be addressed. Rehabilitation nurses assist patients in gaining independence by establishing realistic objectives and treatment plans, working as part of an interdisciplinary team, and frequently coordinating patient care and team activities, offering a very comprehensive view of these issues. All this experience and knowledge opens a wide range of opportunities for professional reflection and thought on which clinical issues demand further attention and formulating a reflective improvement plan.
Identifying a Clinical Issue
One such issue is falling patients, which is a reasonably common problem that occurs in patients with certain chronic diseases, survivors of trauma, and other illnesses and is also especially common among older patients. They are common and can result in fall-related injury and psychological discomfort. Repetitive falls, when a patient falls twice or more, might result in anxiety problems and other conditions. Furthermore, patients falling during treatment in a medical facility might result in customer discontent, increased expenditures, and higher mortality rates. This problem is quite acute and stimulates professional reflection on how to improve the effectiveness of reducing the number of such cases, what steps can be taken by both nurses and other healthcare professionals, and consider possible measures to minimize patient falls.
The listed disorders and aging indicate a short or long-term decline in physiological functioning, which raises the risk of falls in these people. Fear of falling may impact up to 85% of people due to an increased risk of falling and awareness of its negative repercussions (Ang et al., 2020). While the fear associated with a fall might encourage caution, overestimating the danger of falling frequently leads to excessive limitation of physical and social activities, leading to poor condition, functional impairment, and diminished quality of life. As a result, certain people are more prone to falling and are more likely to be hospitalized in a long-term care facility.
Falls in the hospital has the potential to have devastating consequences. It is described as a person unwittingly coming to rest on the same or a lower level of ground (Sullivan & Harding, 2019). Falls cause varying degrees of harm, loss of self-confidence, and inability to move, as well as lengthier hospital stays and higher medical expenditures. Falls in the hospital is a common and serious complication of a stroke. Stroke survivors are more vulnerable to falls in the emergency department, inpatient rehabilitation, and community settings. Falls are the most prevalent consequence during inpatient rehabilitation, affecting 8.7% to 65% of patients (Cameron et al., 2018). It is linked to balance problems, reliance on everyday duties, impulsivity, cognitive impairment, urine incontinence, and a general lack of caring.
The issue is also highly important for elderly patients. Globally, people are living longer, with the proportion of people over 60 years old expected to double from 12% to 22% between 2015 and 2050, and the number of older people expected to rise from 900 million in 2015 to two billion by 2050 (Ang et al., 2020). In Singapore, the proportion of individuals aged 65 and more has risen quickly over the last ten years, increasing from 8.4% to 12.4%. (De Roza et al., 2022). Falls are the leading cause of injury fatalities among the elderly (Casteel et al., 2018). It is estimated that over 646,000 individuals die each year due to falls, with those over the age of 65 being particularly vulnerable (Dolan et al., 2022). Similarly, falls are a significant health concern for Singaporeans over the age of 65. In a study of 720 patients aged 65 and more who were brought to the emergency room for injuries, falls were shown to be the cause of 85.3% of the injuries (Gardiner et al., 2018). The population’s aging and a rising frequency of falls among the elderly indicate an enormous need for more attention to this problem.
Reflective Model
Since patients falls are a rather serious problem, it is relevant to find ways to improve this issue. For this, reflective practice in nursing, both theoretically and clinically, for identifying and understanding the causes of the problem, as well as finding possible ways to cope with them, can become an important tool. The Australian Nursing and Midwifery Board expects nurses to be reflective practitioners (Ingham-Broomfield, 2021). Reflecting on their actions, experiences, knowledge, feelings, and beliefs to form their current education and practice can help registered nurses grow their practice.
To develop a high-quality reflective improvement plan, it is first necessary to identify the most relevant reflective model and theory to utilize in the plan. Reflection focuses on becoming more aware of one’s own knowledge, prior experiences, and beliefs. A reflection model is a methodical approach to personal and situational examination and improvement (Koshy et al., 2018). Reflection models might assist in better understanding one’s own thinking and learning techniques. Furthermore, reflective thinking enables one to link new information to past understanding and experience, examine both abstract and conceptual words, and apply specific tactics to new problems. This may be a very beneficial tool for both personal and business encounters. This is very important in the professional area of nursing for identifying strategies to address specific professional concerns. In general, this tool has the potential to make a substantial contribution to both personal practice and the overall development of health care.
There are many models of reflection, and the first step is to decide which structure supports the work and will best serve the goals. Reflection is often triggered by uncomfortable or negative situations when it is necessary to determine what went incorrect and how it can be improved or corrected in the future (Jiménez-Gómez et al., 2019). However, it can also be started with a positive experience when it is necessary to understand exactly why something worked to be able to repeat the success. Reflection models are often used by healthcare professionals to improve their practice.
There are several reflective models, and the most common are the CARL reflection model and the Gibbs reflective cycle. The CARL Reflection Model provides a framework for professional analysis and improvement aimed at C – context of past experiences, A – actions that have been taken, R – results that have occurred, and L – lessons that have been learned (Ryan et al., 2018). Applying this structure is necessary to provide descriptions for each of these elements. Unlike other reflection models, the CARL method does not require further planned actions. Instead, it focuses on the belief that the practice of identifying new lessons and experiences will affect processes in and of themselves. The Gibbs reflexive cycle is another popular model that involves examining a person’s feelings and how they have affected a situation and reflecting on experience. The Gibbs model suggests using prompts at each step to create a complete structured analysis. The Gibbs cycle of reflection consists of six stages: describing the situation, understanding how the situation arose, evaluating the experience, analyzing, identifying alternative courses that could be taken, and creating a plan of action (Jiménez-Gómez et al., 2019). This model is one of the most popular models among medical professionals. This model will be most appropriate to use in this reflective improvement plan.
Objectives of the Reflective Plan
Writing a reflexive plan includes an analysis of such a problem as the fall of patients from the point of view of the rehabilitation nurse according to the Gibbs reflexive model. Objectives of the reflective plan include describing situations encountered in practice, understanding how the situation arose and what caused it, assessing experience and actions taken, analyzing the situation, identifying alternative courses that could be taken, and creating an improvement plan.
In the practice of a rehabilitation nurse, one has to deal with such a problem as the fall of patients. Upon admission, the nurse conducts a thorough assessment covering all body systems, including medical history and current condition. Aside from physical examination and history collection, rehabilitation nurses investigate a patient’s cognitive and physical functioning to assist define a patient’s baseline in key performance indicators. The patient’s capacity to conduct basic tasks such as eating, bathing, and dressing is monitored from the moment he or she arrives. Nurses construct initial patient safety-related care plans on the first day of stay since they are the first clinicians to evaluate a patient’s cognitive and physical performance. The rehabilitation nurse may assess that the patient’s failure to sit unaided for five seconds, along with a high fall risk score, suggests that fall prevention measures are required. Interventions will then be implemented promptly under the nurse’s plan of care.
Unfamiliar surroundings, acute illness, surgery, bed rest, medications, treatment, and placement of various tubes and catheters are common problems that put patients at risk of falling. Even with appropriate patient communication and informing, proper care, and close supervision by nursing staff, patients may not follow directions, which can lead to falls. The severity of falls in hospital patients endangers patient safety and can be a financial strain on the patient’s family and healthcare providers. The severity of hospital falls is linked to both patient-specific and environmental and organizational variables (Ghosh et al., 2022).
If a patient falls in the hospital, the response algorithm will usually include steps like calming the patient, calling for help if necessary, checking for trauma, treating as indicated, assessing vital signs and neurological observations. Notifying the responsible nurse and the patient’s family and ensuring that fall risk assessment and interventions are updated and implemented is also essential. Determine the reason for the fall and direct response to lessen the chance of patients falling again. Typically, an urgent fall assessment is performed at the bedside, involving all present staff members, the patient, family, carers, and an interdisciplinary team. The objective is to identify the elements contributing to falls and devise preventative strategies. When such an incident occurs, it must be analyzed and considered. It is necessary to analyze whether anything was different in working with this patient compared to other patients who did not fall, although they had risks. It is worth considering whether there were available ways to avoid the fall before it happened. If it is possible to find such methods, then it is worth analyzing their applicability in work with future patients.
Critical Literature Review and Strategies to Improve the Practice
This problem is indeed significant not only in professional reflection but also in general health care and is the subject of many studies. In a study by Sullivan and Harding (2019), an association was found between communication disorders and increased rates of falls. The relationship between falls and major communication impairments was investigated in patients with and without functional communication in a hospital setting. Multivariate logistic regression to investigate factors that may predict falls, such as the presence or absence of functional communication, is also the subject of research. (Ridki et al., 2021). Patients who were unable to convey their fundamental requirements were nearly twice as likely to be hospitalized as those who could communicate. The most powerful independent predictor of fall frequency was a lack of functional connection. As a result, significant communication problems may be underestimated as a risk factor for post-stroke falls. This is also correlated with professional practice and should be considered in assessing the risks of falling patients.
The aging population is a substantial public health issue across the world. Every year, one in every five adults aged 65 and up fall, and one in every five sustain a fall-related injury (Teng et al., 2021). Singapore will join Japan, the United Kingdom, and France as a “super age” country by 2026, with one in every five inhabitants aged 65 or older (Teng et al., 2021). Falls are not only common, but they also frequently have significant health implications, such as hip fractures, which raise the chance of mortality within a year (Goh et al., 2021). Furthermore, the treatment of falls is expensive, as evidenced by hospital expenditures and lost family and caregiver productivity. As a result, it is also essential to provide further attention to this age group in this situation. Physical therapists, for example, can assist decrease and preventing falls by addressing modifiable risk factors for falls, such as poor gait and balance. Educating older patients about the need for this recommendation and advocating for them can help prevent not only falls but also a variety of other disorders.
Physical activity might become the most prevalent and beneficial component of single, multiple, or multifactorial therapies to lower the risk of falling. Giving elderly patients free access to exercise programs, as well as including them in obligatory rehabilitation from other diseases where possible, can also help to reduce the number of falls (Fonseca et al., 2020). Nurses on their side can also emphasize the importance of exercise to patients. As nurses spend more time with patients than other healthcare workers, they have a major impact on patient experiences and develop a more trusting relationship with them.
It is critical to assess the factors related to the severity of a fall that may impact the execution of any fall prevention strategy on a regular basis. Fractures are one of the most common major injuries sustained following a fall (Florence et al., 2018). The conventional strategy to fracture prevention has been to increase bone mineral density, with a combined therapeutic approach to fall prevention often absent. Falls and fall risk can be reduced using multifactorial intervention options based on clinically assessed individual requirements. This method includes assessing and managing patients with falls, mobility, and balance issues, providing time-limited intervention, advising and referring patients to mainstream services, and providing education and training to carers and health professionals.
Fall prevention techniques for older community-dwelling persons may also lessen fall-related injuries. A study by Gomez et al. (2019) was conducted in which researchers adopted and assessed a novel integrated care model in the outpatient environment for evaluating and preventing fractures and falls in Nepean Hospital’s Fall and Fracture Clinic (FFC) Penrith, New South Wales, Australia confirmed this. The researchers found that interdisciplinary FFC might produce a significant reduction in falls and fractures in high-risk adults in as little as six months. Instructing nurses in these techniques and providing appropriate resources for patients can help address the problem of falling patients.
Some patients with particular diseases are not only at a higher risk of falling, but they also require unique treatments to address their fall problem. Such characteristics can be found in patients suffering from kinesiophobia. This condition is characterized as a dread of movement and activity caused by a worry of painful injury or re-injury (Oguz et al., 2022). It can impact a patient’s physical activity, balance, and fear of falling. Patients with Parkinson’s disease are more prone to have high levels of kinesiophobia, which leads to less physical activity, worse balance, increased disease severity, and a fear of falling (Thiamwong, 2020). Rehabilitation programs to maintain functional performance and measures to prevent falls in such patients should be developed considering the presence of kinesiophobia. Falls and the fear of falls in patients with Parkinson’s disease can be reduced through effective clinical prevention and treatment (Liu et al., 2022). Gradual exercise intervention for patients may help to regain some of their behavioral abilities in connection to physical function and prevent falls.
Unforeseen falls in a healthcare facility can also be caused by a mismatch between objective and subjective risk of falling and related factors in patients. Such a mismatch may arise when the patient’s condition has altered (Lim et al., 2018). Although the patient is familiar with his sickness and the symptoms linked with the risk of falling, changes might exacerbate the condition. Fall risk underestimation and overestimation have been linked to various profiles depending on cognitive and psychological state, falls, and fall-related behavioral consequences (Hauer, 2020). As a result, it is critical for nurses to estimate patient risk independently, if feasible, and to account for subjective judgment discrepancies in the complete fall risk assessment and development of specific fall prevention programs for such patients.
To prevent falling patients, it is essential for nurses to pay attention to informing the patient’s family or caregiver. The concerns of carers affect the physical, psychological and social health and organization of patient care (Ang et al., 2018). Sometimes anxiety and fear that the person receiving guardianship will fall and be injured in the caregiver are even higher than in the patient himself. Caregivers, due to excessive concern, can use their influence to limit the physical activity of the ward, which will lead to a further deterioration in the motor status of patients and the deterioration of their physical qualities and mental and psychological state (Slatyer et al., 2019). In the future, such restrictions are likely to lead to repeated falls and exacerbate the severity of their consequences (Kiyoshi-Teo et al., 2019). It is essential for nurses to identify such overprotective caregivers and inform them of the consequences of their behavior. This will also improve the problem of falling patients.
It is impossible to prevent all falls; they will still occur. For this reason, it is crucial to minimize the severity of the consequences of such falls. To do this, it is necessary to identify the emergency in time and provide assistance (Stevens et al., 2018). The creation of a health monitoring system based on a wearable sensor has significant promise in the field of rehabilitation and has piqued the interest of the scientific community and industry (Suriani et al., 2018). The purpose and motivation in this field are to concentrate on the use of wearable technology to monitor geriatric or rehabilitation patients at home to decrease care resources and expenses (Ferreira et al., 2022). An accelerometer, a wearable sensor, is utilized to emphasize the therapeutic use of fall detection during rehabilitation treatment.
Despite the decrease in the number of falls in hospitals, they pose a severe problem for patient safety. Falls of hospitalized patients place a heavy burden on patients and medical organizations. Despite many positive developments in the provision of fall prevention interventions, the problem remains serious. Based on a rehabilitation nurse professional practice, this reflective improvement plan offers a range of strategies that would help improve the problem of falls and make the patient and staff experience more securer, more comfortable, and safer.
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