Evidence-Based Practice & Applied Nursing Research

Evidence-Based Practice & Applied Nursing Research BY Judi Prescription of the research was performed within an ethical framework of clinical practice. The Main problem that participants expressed were that they at times had negative interactions with health care professionals. They felt that not enough respect and personal interaction was afforded. The model used for research is the experimental-Model, it is qualitative research. The focus of the study was on women age 29-44 suffering with the debilitating effects of formability.

It is discussed that the authors believes it is important to find ways to promote adherence to the aerogram. They also recommend a more mixed method of study designs which may produce better outcomes. Cultural, economic factors may also be a factor in adherence. The author discusses the use of fractionation as an alternative to the three prescribed exercises. In fractionation the participant would perform two or more shortened sessions of no less than 10 minutes of activity instead of a single continuous session totaling the same duration as the shortened sessions.

Both the SCAMS and CDC guidelines recognize that this form of training can yield beneficial results and has been found to encourage participants to be more compliant with the exercise program. Ethical concerns include obtaining approval through the institutional review board (RIB), which is an ethics committee that is independent of the study and who are designated to approve, review and monitor the research. The RIB determine through risk analysis whether the study is feasible. The RIB regulates human scientific studies to allow for ethical treatment of test subjects.

Other ethical concerns include maintaining confidentiality, and anonymity of the patients, and protecting patients involved in the study from injury. It was examined whether the researcher could have performed a quantitative research design. In quantitative research information is gathered and measured using an instrument then statistically analyzed. The instruments are converted into numbers, but will only work with quantifiable concepts that can be turned into numbers. This form of analysis is more in line with clinical trials and predictive studies (Langford, R. 2000). This would not be a functional form of study in this case.

In the study of efficacy of exercise in women suffering with formability a more in-depth analysis of the test subjects was required. Variables to the study included more than one form of exercise, length and times for exercise, and length of the study. The author was not able to clearly prove whether exercise for formability is an effective measure of treatment. Additional study is required, and does not discuss falls and whether exercise affected reduction in falls. Long term studies were inclusive due to the high dropout rate from the study. Part 2 Fall related injury is of a major concern for the elderly, and the frail.

Falls are the number one cause of fatal and non-fatal injury and occur in one in every three adults physician (PC). This may be due to fear and lack of knowledge that there are interventions available to help restore strength and balance. In 2010 there were 21,700 unintentional deaths related to falls in the US, other Injuries occurred such as fractures, head traumas, and lacerations. There are also psychological after effects of falls, such as anxiety and a fear of falling (“CDC – Older Adult Falls – Falls Among Older Adults: An Overview – Home and Recreational Safety – Injury Center”).

The fear of falling can result in a decrease in activity and eventually frailty. Falls don’t Just cost the individual time, and strength in recuperation But financially it affects patients as they often have to be in long term care facilities for many months, which prevents hem from being able to take care of their daily expenses such as utilities and rent, unless they have a reliable caregiver. Fall risk can increase with certain medications such as sedatives, diuretics, interpretative, and anticonvulsant. It is important that patients are properly instructed about their increased risk of falls when visiting with the PC.

But maintaining strength, flexibility and endurance are by far the most important way of decreasing the risk of falls. The author will prove the psychological and physical benefits of exercise in relation to reducing falls in the elderly population. Busch, Angela. Best practice: E-Model?prescribing physical activity and exercise for individuals with formability” Physiotherapy Theory and Practice, 24(3): 151-166, 2008. The author discusses Formability (FM), which is a debilitating neurological condition. The research attempts to prove the health benefits of physician prescribed physical activity to decrease symptoms.

The goal is to improve and maintain physical fitness. The authors used a meta-analysis approach of study and have divided leisure time physical activities into three criteria, which include competitive sports, regular exercise such as strength training and flexibility exercises, ND recreational physical activity. The researcher has used a collaborative approach, involving clinicians. The author’s looks to the clinicians to provide their experience and expectations to better meet the needs for the clients in the study.

Minimal research was performed on the benefits of stretching, there were benefits noted in acute exercise that is designed to the individual; this included decreased pain, depression and micro trauma. Multiple sources were used to perform the study. Problems found with the study were adherence of clients involved in the study to stay consistent with the plan. Long term benefits were not seen past two years. The model used for research is the experimental-Model, it is qualitative research. It is discussed that the authors believes it is important to find ways to promote adherence to the program.

They also recommend a more mixed method of study designs which may produce better outcomes. Cultural, economic factors may also be a factor in adherence. Fractionation is the performance of two or more shortened sessions of no less than 10 minutes of activity instead of a single continuous session totaling the same duration as the shortened sessions. Both the SCAMS and CDC guidelines recognize that training using fractionation can yield beneficial results and has found to encourage better adherence to the exercise program. The author was not able to clearly state whether exercise for formability is an effective measure of treatment..

Ethical considerations for this study are maintaining anonymity of the test subjects, getting informed consents signed by each participants and receiving permission for be tailored to the client. This can be accomplished, through a simple interview questionnaire, where it is determined what the clients’ interests are. A fitness test to notate what the current level of functioning is followed by review of the results, patient’s current weight, psychosocial issues such as depression, and medication profile. The researcher can then create a feasible plan, and offer the choices of home or clinical setting for the exercise plan that is formulated.

Provide the client with access to support when symptoms are being exacerbated and log daily symptoms, whether they are improving or worsening during the study (Busch A. Thiele (2008). Squiggle, P. Prevention of fall-related injuries: a clinical research agenda 2009-2014. Journal of Rehabilitation Research & Development Squiggle discusses the changes needed to reduce fall risk and prevention in regards to patient safety. The author discusses the implementation science mode of research and uses a patient centered multiracial and individualized care plan.

The focus of the studies is on the elderly, but lumps all fallers into one group. Fall protection and injury prevention, emphasizing therapeutic risk associated with activity and community participation. This new agenda also recognizes the need to segment high-risk patient populations to identify unique risks and tailor interventions (e. . , peripheral enumerator, wheelchair dependent individuals and fallers) using a new three-dimensional technique to assess gait and balance as well as other key risk factors..

Ethical considerations for this study are maintaining anonymity of the test subjects, getting informed consents signed by each participants and receiving permission for the study by a review board. The author focuses on primary health promotion, patient safety, in relation to clinical intervention, using an interdisciplinary approach. The study is quasi-experimental and incorporates a home hazard assessment, and cardiac assessment. The researcher incorporated nutritional supplementation, and group delivered exercise. The Study was incomplete and did not include certain high risk populations such as Parkinson, enumerator and osteoarthritis.

The author discusses the increase fall risk due to the need to include medication reconciliation and the need to assess cognitively and physically impaired individuals early to prevent falls (Squiggle, P. (2009). There was not a control group in which to compare efficacy of the exercise therapy used, nor was the study individualized to promote adherence to the program. Gregory, H. , & Watson, M. 2009). The effectiveness of ATA Chi as a fall prevention intervention for older adults: a systematic review. International Journal of Health Promotion & Education, 47(3), 94-100.

The article is a systematic review that expounds upon the effective use of ATA Chi in reducing falls in elderly adults living in the community. The author conducted a systematic review of literature related to the subject matter. A total of six Randomized Trials were performed and included 1857 adults over rays old mainly female, who had one or more falls. ATA Chi was provided as an intervention, and randomized control trials ere performed. It was conducted for a duration that ranged from 15 weeks to two years. The author accessed 8 electronic databases and found 66 potentially relevant articles.

ATA Chi was the focus of study due to it being a health promotion form of exercise. The studies were conducted by nurses, ranged in characteristic from frail control group for the healthier adults. For the more frail adults there was not a significant statistical reduction in fall risk. Problems found with the study, were that author felt concern with the literature reviewed being comprehensive high quality and free from bias. Two independent reviewers were used to combat this issue, and provided Judgment on the experimental, randomization process, blinding, as well as the percentage of participants that followed up.

A third reviewer was available but was not used in case of discrepancies in findings. Two studies that stood out to the author was a ATA Chi program that was performed for 60 minutes for 4 weeks, then increased to twice weekly sessions for 16 weeks, each session was followed by a 30 minute social component. The second ATA Chi was performed 3 times a week, and behavioral and psychotherapeutic methods were incorporated by using a multi- capillary approach. Nurses and social workers were part of this study and addressed reduction in the fear of falling once monthly.

It was found that the ATA Chi intervention group had a significant reduction in falls compared to the control, and stretching groups. This was noted in both frail and healthier adults over 60 who did not have previous falls. ATA Chi shows to be evidence based practice to incorporate in a falls prevention program/ Nurses should be educated to the benefits of this treatment modality, and assess their patients in the community for the appropriateness of ATA Chi for falls prevention. Make-Lye, 1. , Hempen, S. Gang, D. , & Shekel, P. (2013). Inpatient fall prevention programs as a patient safety strategy: a systematic review. Annals of Internal Medicine, 158(5 Pat. 2), 390-396. The author’s focus for this study was on fall prevention for patients in acute care hospitals. A multiplication inpatient fall program was initiated to provide an evidence based way of reducing falls. The range of study were on hospitals in the US, Singapore, France and United Kingdom. The range of participants was from 199 to 7254 per hospital.

A multidisciplinary approach was used where a committee was formed, interventions were pilot tested, and information technology was used to provide data about falls, fall prevention, staff education and training, and staff response to training. Interventions incorporated was patient education, fall risk identification over the bed side, alerts on the wristband, appropriate foot wear, toileting schedule, and review following the fall to identify causes. The hospitals used either before and after or randomized controlled trials. The study revealed that multiplication programs are effective in reducing falls.

Review was performed by a clinical and non-clinician, hey found there was statistical improvement in intervention groups when compared to the control. The study found that multiplication in facility prevention programs resulted in a significant reduction in falls. There were a combination of quasi- experimental, before and after and experimental methods reviewed for this study. The author also addresses the need for an effective safety infrastructure where the culture of the clinical team is always revolved around patient safety and teamwork.

The article states that multiplication interventions are effective in reduction of inpatient falls but is inclusive since further knowledge base is required to identify the appropriate bundle of interventions needed to effectively reduce falls.. Ethical Moore, D. , & Ellis, R. (2008). Measurement of fall-related psychological constructs among independent-living older adults: a review of the research literature. Aging & Mental Health, 12(6), 684-699. The author discusses the psychological difficulties that are associated with falls.

This is debilitating, causing loss of confidence and anxiety, leading to a loss of function due to voluntary restriction and decrease in independence. The study consisted of older population living in the community. The Falls efficacy scale or Tinned scale; a fall risk index for the measurement of the elderly based on the number of chronic disabilities. Is compared with the Survey of Activities and fear of falling in the elderly (SAFE); the SAFE is more effective in determining whether there is a fear of falling leading to activity restriction but it is a more time consuming test.

This experimental study contained individuals that were afraid of falling and not afraid of falling and was conducted using a face to face format. The Dinette was found to be a good predictor not Just of fall but a predictor of future falls. The researcher concludes that a standardized test for psychological fall prevention needs to be separate from a fall risk assessment to be more inclusive for high risk individuals.. Ethical considerations for this study are maintaining anonymity of the test subjects, getting informed consents signed by each participants and receiving permission for the study by a review board.

Clemson, L. , Taylor, K. , Kenning, H. , Cumming, R. , & Swan, M. (2007). Recruiting older participants to a randomized trial of a community-based fall prevention program. Australian Journal On Ageing, 26(1), 35-39. The author discusses methods used to recruit elders for a fall prevention program. Study consisted of community residing individuals over 70 with history of falls, who were in randomized trials for 2 hours a week for 7 weeks. Occupational therapy worked in conjunction with the study. The author encountered that recruitment was difficult due to target group lack of knowledge on the subject of fall prevention.

The recruitment was conducted over a 26 month period. Media and mail outs were used with 732 people responding, and 310 were recruited. Those excluded were persons who were homebound, and had cognitive impairment. The age ranged from 70 to 99 years of age, mostly women where 65% of which had a fall that past year. The sample set was believed to be a good representative of the general populace. It was concluded that personalized mail outs was the most effective method of recruitment for this study.

The most active elders were those who had been referred by friends or family members. While health professional referral was the least useful due to being more frail or having a lower socio economic status. The randomized trial was successful in the goal of recruiting the target audience to commit to a 7 week health intervention. This was due to prompt reply to inquiries, focused and positive staff who patiently answered questions and transport and venue location was convenient. Reap, K. , Lamb, S. , Reheard-Beer, L. , Lineman, IS. , Irishman, IS. Klein, J. , & Becker, C. (2010). This was an experimental study where no randomization was used, but the Baden-Wringers homes were the control. Effect of a statewide fall prevention program on incidence of femoral fractures in residents of long-term care facilities. Journal Of The American fall prevention program in relation to femoral fractures in nursing homes. The study consisted of 5000 non randomized patients in long term facilities in Germany over a two year period. Femoral fracture vs.. Other serious injuries was the primary focus.

The study was performed based on an earlier study in 1998 where a cluster- randomized fall prevention trial in six nursing homes resulted in a 44% decrease in falls. The author discusses a modified version of this study was performed using a multiracial fall prevention program, where an exercise program consisting of trench and balance training was used for an hour weekly, physical therapists conducted these programs, as long as the individual was able to stand with support they were The study population was 9,077, the control group A was 23,250, control group B was 20,333.

The modified study did not show a reduction in femoral fractures, and is felt this may be because there was either inadequate adherence to the program or inadequate uptake due to staff being inconsistent. Analysis of the study focused on time at risk from the start date of fall intervention/ admission to the nursing home to the time of discharge/death. Proportional hazard regression models were also applied for two years beginning with the time intervention began, and results were adjusted based on the size of the home, sex and age of the patient.

Nursing homes with fewer than 50 beds were excluded. Concerns with this study was contamination due to the program covering too large an area, it encompassed all regions of the federal state. Femoral fractures did not decrease the author believes it was due to lack of proper falls prevention teaching of nursing staff, and inadequate adherence to the falls prevention program by patient and staff. The author also feels that participation of candidates may have been too low, or they may have not have been physically appropriate for the study. Dozen, H. Using multiple data sources to answer patient safety-related research questions in hospital inpatient settings: a discursive paper using inpatient falls as an example( 2011). This is a qualitative study which uses a survey and was performed targeting 2309 licensed and unlicensed staff in 27 adult care units, of which 808 participated. This was a quasi- experimental study where The author discusses that intrinsic and environmental actors need to be assessed especially now that Medicare as of 2008 no longer reimburses acute care hospitals for costs related to hospital related falls.

The focus discusses the fact that meaningful approaches need to be made to reduce in-patient falls. The author uses multiple data sources to review both archived data such as, interviews with focus groups, public data set, published legal cases etc. A multidisciplinary approach, focused around nursing, where it was found that hospitals that had fall prevention guidelines in place were more likely to have falls than hospitals that did not.

However, nurses who received training using a multifaceted approach acquired more of a knowledge base in order to better perform fall risk assessments. There were two testable models used a conceptual model funded by the Agency for Healthcare Research and Quality from 2009-2011, where injurious and non-injurious falls were assessed in the response to call lights. It was also discussed the patients perceptions to timed response to the call light, age, restraint use, mental status and hearing.

The second model addressed a patient centered nursing model that promoted positive patient outcomes, developed by involved in the plan of care and patient safety. The author concluded that multiple data sources are an effective way of measuring data related to falls, this will assist policy makers on the efficacy of fall prevention programs. Those interventions for fall risk must be feasible, and health care staff must be active participants in complying with fall prevention. Ill-Ambrose, T. Khan, K. , Eng, J. , Sillies, G. , Lord, S. , & McKay, H. (2005). The author discusses The beneficial effects of group-based exercises on fall risk profile and physical activity persist 1 year post intervention in older women with owe bone mass living in Vancouver: Follow-up was performed after withdrawal of exercise. The study lasted 25 weeks, and was performed at community centers. The author uses a quasi-experimental approach whether falls are reduced 1 year after exercise ceases.

A randomized original trial examined The forms of exercises used prior to the year are resistance training, agility training and stretching in which participants were randomly assigned. The study group consisted of 98 women aged 75 to 85 with low bone mass. The two tools used to assess the outcome was the Physiological Profile Assessment. The second was the Physical activity Scale for the Elderly. It measured the current physical activity level, and formal exercise, which consisted of resistance, agility and stretching.

The study concluded that falls were reduced in all three groups. Mean risk value was 43% lower than the baseline for resistance training group, 40% lower in agility training and 37% lower in the general stretching group. At 8 months 93 women were re-assessed, and 89 at 12 months to assess whether falls had occurred or decline in health. Four of the participants suffered conditions from the resistance training which included heart attack, and ass of independence, a stretching participant fell and fractured her sacrum resulting in debility.

Over a 12 month period a total of 16 participants fell, but overall fall reduction benefits extended for at least 12 months after the conclusion of the study, while physical activity increased. It is believed by the author that the withdrawal of the exercises may have contributed to the falls that occurred. Group based resistance and agility training had the best outcomes. It would have been better to continue the program past the 25 week period at least for a portion of the participants as a control. Kate, M. , Simi, K. Hiroshima, T. , & Shoeing, M. (2006).

Development of an exercise program for fall prevention for elderly persons in a long- term care facility. Japan Journal Of Nursing Science, 3(2), 107-117. The research consisted of the development of an evidenced based nursing exercise program for fall prevention for elderly individuals in a long-term care facility. The test subjects muscle strength was found to be 50% lower than individuals of the same age living in the community. A study by Kate revealed that within a year mobility of institutionalized individuals markedly decreased, resulting in a 50% increase in falls.

The purpose of the program was to increase balance, muscle strength and mobility in the lower extremities, while increasing self-efficacy for fall prevention. This program was extensive and included warm-up, stretching, muscle strengthening geared to the lower extremities, toe exercises to decrease postural sway and fall and overprotective neuromuscular facilitation followed by a cool down. It was a quasi- experimental study consisting of a clinical trial of subjects recruited from two long term facilities that lasted 3 months. Interventions were measured before and after participants and 14 control group.

Outcomes values were measured as mobility, muscle strength of lower extremities, fall efficacy, postural sway, and number of fallers and falls. The researcher addressed three basic beliefs; the frail elderly can exercise safely, without emotional stress, and that exercise can be used as a regular activity of daily living. Ethical considerations for this study included that candidates and family members were informed of the purpose, methods and measurements and potential risks related to the research, and was performed according to guidelines of the Helsinki Declaration.

Patients’ rights were explained which included their right to outdraw at any time. Hospital administrators and Primary care physicians were contacted prior to the study, physicians signed consents to allow for the elders participation in the study. Written informed consent was obtained by each participant, for individuals with cognition issues the family and physicians were also informed. The Friedman test was used to analyze the effectiveness of the outcomes. The intervention group improved balance, and there was a decrease in fallers and falls.

Falls decreased from 6 to 1 . Muscle strength and fall efficacy did not increase. The foot exercises accounted in large part for the decrease in falls. The exercise program showed enough merit to prove to be an evidenced based fall prevention method for the elders and has been put into practice. Garcia, A. , Markings, D. , Uncle, L. , Smith, E. , & Ramsey, R. (2012). Promoting Fall Self-Efficacy and Fall Risk Awareness in Older Adults. Physical & Occupational Therapy In Geriatrics, 30(2), 165-175. Don. 3109/02703181. 2012. 81431 The research based on a malfunction modified fall prevention program called “stepping on” it was developed by an occupational therapist and its goal is to increase fall self-efficacy, encourage behavioral change while reducing falls in older adults. The study consisted of seven 2 hour sessions over a 7 week period, and focused on lower limb balance and strength exercises, medication management, home safety, vision and mobility assessment, and foot wear used. A follow up home visit and 3 month booster session was conducted to support follow through with fall prevention strategies.

The study consisted of 19 women age 69 to 96 living independently or in an assisted living facility, with no cognitive or mental disability which was determined through a mini mental status exam. Recruitment was done through council meetings, posting flyers, sending arsenal letters of invitations, and postings on bulletin boards. Ethical considerations included having the study approved through the Dominican University of California Institutional Review board, informed consents were obtained from each participant.

The study was a mixed-method, one group, non-experimental, pretest-posters design. One set of repeated measurements were taken before and after the intervention. Measurements for the data collection used the falls efficacy scale, the researcher also used the Remember test to test static balance when a person eyes are closed while standing upright with arms at sides. The MIMES test is a cognitive screening tool to test the ability of the participant to learn fall prevention strategies with a score of less than 23 indicating problems with cognition.

The most prevalent conditions for participants were arthritis, visual impairments and hypertension. The study was limited to Caucasian women only, who were middle to upper class, there was no control group The stepping on program led to an overall awareness of fall diversity in race, sex and economic background. Logged, 1. , Queue, P. , Averaged, A. , Wizen-Spouseless, R. , Wellness, S. , Iberia-Sinatra, S. , & Goes, B. 2009). Lack of effect of ATA Chi Chuan in preventing falls in elderly people living at home: a randomized clinical trial.

Journal Of The American Geriatrics Society, 57(1), 70-75. Dot: ATA Chi Chuan on elderly people living at home with a high risk for falls. This was a randomized double blind control trial and involved 269 people with an average age of 77. Subjects were invited by mail and screened through a short telephone survey. The intervention group received ATA Chi Chuan hourly twice weekly for 13 weeks. The control group did not, both groups received brochures on fall prevention. Calendars ere provided and participants were instructed to record in it daily, fallen, nearly fallen or not fallen.

Falls were defined as coming to rest unintentionally on the ground, while almost fall was defined as catching or leaning on something. Calendars were collected monthly by mail. Participants who did not send calendars in were contacted by the blinded research assistant who would assist the participant with completion by phone. Outcome measures included the Falls efficacy scale for fear of falling, the Physical Activity Scale for the elderly, and the Growing Activity Restriction scale for functional status.

Heart rate, peak flow and blood pressure were monitored throughout the study. At the end of the 3 month and 12 month period a blinded research assistant performed the balance measurements. Measurements were the number of falls over 12 months, as well as balance, fear of falling, blood pressure, peak flow, and functional status. Ethical considerations for this study are maintaining anonymity of the test subjects, getting informed consents signed by each participants and receiving permission for the study by a review board.

Following 12 months falls risk were not reduced in the ATA Chi Chuan group when compared to the control group. Of the 138 ATA Chi Chuan participants 25 withdraw before the first lesson. 65 attended 21 lessons; 80% of the lessons. Main reasons for noncompliance were health problems, and transportation problems. There were 42% of ATA Chi Chuan participants reporting falls vs.. 45% of the control who reported falls. ATA Chi Chuan showed no improvement in falls in this study, nor did it improve blood pressure, resting heart rate or fear of falling.

The researcher also concludes the study population may have been a factor in disproving his theory as the participant were not frail did not have a fear of falling and had minor balance problems. There was no significant balance improvement noted in either group, which is necessary in fall reduction. 85 Participants completed self-reported practice at home, 62 participants practiced twice a week or more, while 18 practiced for 10 minutes or longer per session. The study would have been more effective if there was a more controlled method of teaching ATA Chi Chuan.

The fact that test subjects were able to say they exercised when there was a high probability they did not, also may have contributed to the failure of this study. Has, R. , Maloney, S. , Passenger, E. , Keating, J. L. , Sims, J. Molly, E. , & Haines, T. (2012). Clinical Decision Making in Exercise Prescription for Fall Prevention. The study consisted of telephone interviews with 24 expert physical therapists that were with and found that 8 practitioners in each subset would provide a 96% probability of comparison to at least one third of their peers.

There was a 72% positive response to interview requests. The objective of the study was to analyze Physical Therapists decision making processes when prescribing fall prevention exercises. The design is A qualitative study from a phenomenological perspective and was performed to determine the decision making processes used to prescribe exercises to prevent falls. This was a semi structural study, a combination of purposive and snowball sampling, the three forms of exercise studied was group, face to face individual and unsupervised home exercise programs.

The Therapists participated in telephone questionnaires where they gave commentary on their approach to the content of exercise programs, strategies used to encourage sustained participation, key safety issues when performing any of the three exercises, and what factors were considered when prescribing a particular exercise program.. Health care reasoning was utilized to determine the appropriate exercise plan for each patient. Psychosocial reasoning was not part of this study, clinical assessments influenced the exercise regimen. The study incorporated 5 stages of data analysis: 1. Familiarity with the data 2.

Separating the data using a thematic approach 3. Indexing and applying codes 4. Charting themes 5. Mapping the data to identify associations between categories. Therapists who were experts in fall prevention, adopted an individualized rather than a cookie cutter approach. Exercises were individualized to promote safe implementation and adherence to the program. The decision making was based on client’s perception of illness and stumbling blocks, functional difficulties, therapist perception of patient compliance, and safety performing the exercises, as well as therapist’s knowledge of the principles required to prescribe the exercises.

Exercises were adjusted to fit the ability of each person. Therapists who participated in this study also discussed evidence based practices that affected their decision making. The author calls for additional research to determine whether it is economically efficient or clinically effective as a cookie cutter program. Balance exercises were not part of the study. The article does not clearly determine whether exercise reduced falls in this study.

Analysis of 13 research articles on fall prevention in the frail and elderly discussed the importance of a fall risk assessment, there does not appear to be enough long term studies that analyze the importance of exercise past one year. All measures were taken in each study to prevent ethical issues, this included getting approval from a review board, obtaining appropriate signatures, maintaining confidentiality, clauses allowing participants to id’s-enroll at any time, and full disclosure of what ACH study entailed so that participants were educated on their role in the study, and were able to ask questions, prior to enrolling.

Research types varied and included experimental; which provided an explanation and evaluation and provided a random assignment, quasi-experimental; which provided an explanation and evaluation but contained no random assignment, meta-analysis; which relied on research data that was already collected and qualitative; which is a more observational method of research. Adherence to the exercise program was also a factor due to distance of

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