NSG7020 – Week 5 project

Week 5 Project

Instructions

Nurses are typically less familiar with qualitative studies than quantitative. When doing a thorough literature review to find external evidence, it is important that you consider all points of view. This assignment will provide you with an opportunity to read and appraise a qualitative study and objectively determine its worth to inform your PICOT question. ( My week two PICOT question: In adults with obesity (P), how does participation in a structured weight management program (I), compared to self-directed weight loss efforts (C), affect long-term weight maintenance (O) over a 12-month period (T)?  

Tasks:

In Submissions Area, you appraised quantitative evidence from a reference list that was provided. You then set up an Evaluation Table for your individual PICOT question. In this week, you will add to that table by adding the critical appraisal of a qualitative study. Use the reference list provided in Submissions Area and critically appraise the qualitative study.

Compile the following:

• A copy of the RCA form for the qualitative study from the Reference List using the appropriate RCA checklists. (Attached)
• A completed Evaluation Table that includes the quantitative and qualitative studies

Page 1 of 7

Evidence, Effectiveness, and Clinical Quality
©2014 South University

Reference List—Scenario 2

Barnett, A., Smith B., Lord, S. R., Williams, M., & Baumand, A. (2003). Community-based group exercise
improves balance and reduces falls in at-risk older people: A randomized controlled trial. Age Ageing,
32(4), 407–414.

Abstract

Background: Recent studies have found that moderate-intensity exercise is an effective intervention
strategy for preventing falls in older people. However, research is required to determine whether
supervised group exercise programs conducted in community settings with at-risk older people referred
by their health care practitioner are also effective in improving physical functioning and preventing falls in
this group.

Objectives: To determine whether participation in a weekly group exercise program with ancillary home
exercises over 1 year improves balance, muscle strength, reaction time, physical functioning, and health
status and prevents falls among at-risk, community-dwelling older people.

Methods: The sample comprised 163 people residing in South Western Sydney,
Australia, aged over 65 years identified as at risk of falling, using a standardized assessment screen by
their general practitioners or hospital-based physiotherapists. Subjects were randomized into either an
exercise intervention group or a control group. Physical performance and general health measures were
assessed at baseline and repeated 6-months into the trial. Falls were measured over a 12-month follow-
up period using monthly postal surveys.

Results: At baseline, both groups were well matched in their physical performance, health, and activity
levels. The intervention subjects attended a median of 23 exercise classes over the year, and most
undertook the home exercise sessions at least weekly. At retest, the exercise group performed
significantly better than the controls in three of six balance measures: postural sway on the floor with eyes
open, postural sway on the floor with eyes closed and coordinated stability. The groups did not differ at
retest in measures of strength, reaction time, and walking speed or on Short-Form 36, physical activity
scale for the elderly, and fear of falling scales. Within the 12-month trial period, the rate of falls in the
intervention group was 40% lower than that in the control group (IRR = 0.60, 95% CI 0.36–0.99).

Conclusions: These findings indicate that participation in a weekly group exercise program with ancillary
home exercises can improve balance and reduce the rate of falling in at-risk, community-dwelling older
people.

Page 2 of 7

Evidence, Effectiveness, and Clinical Quality
©2014 South University

Chang, J. T., Morton, S. C., Rubenstein, L. Z., Mojica, W. A., Maglione, M., Suttorp, M. J., . . . Shekelle,
P. G. (2004). Interventions for the prevention of falls in older adults:
systematic review and meta-analysis of randomized clinical trials. British Medical
Journal, 328(7441), 680–683. Retrieved from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC381224/pdf/bmj32800680

Abstract

Objective: To assess the relative effectiveness of interventions to prevent falls in
older adults belonging to either a usual care group or a control group.

Design: Systematic review and meta-analyses.

Data sources: Medline, HealthSTAR, Embase, the Cochrane Library, other
Health-related databases, and the reference lists from review articles and
systematic reviews.

Data extraction: Components of falls intervention—multifactorial falls risk
assessment with management program, exercise, environmental
modifications, or education.

Results: Forty trials were identified. A random effects analysis combining trials with
risk ratio data showed a reduction in the risk of falling (risk ratio 0.88, 95%
CI 0.82–0.95), whereas combining trials with incidence rate data showed a reduction in
the monthly rate of falling (IRR 0.80, 0.72–0.88). The effect of individual components was assessed by
metaregression.

A multifactorial falls risk assessment and management program was the most effective component on risk
of falling (0.82, 0.72–0.94, NNT 11) and monthly fall rate (0.63, 0.49–0.83; 11.8 fewer falls in treatment
group per 100 patients per month). Exercise
interventions also had a beneficial effect on the risk of falling (0.86, 0.75–0.99,
NNT 16) and the monthly fall rate (0.86, 0.73–1.01; 2.7).

Conclusions: Interventions to prevent falls in older adults are effective in reducing both the risk of falling
and the monthly rate of falling. The most effective intervention was a multifactorial falls risk assessment
and management program. Exercise programs were also effective in reducing the risk of falling.

Page 3 of 7

Evidence, Effectiveness, and Clinical Quality
©2014 South University

El-Khoury, F., Cassou, B., Charles, M-A., & Dargent-Molina, P. (2013). The effect
of fall prevention exercise programmes on fall induced injuries in community
dwelling older adults: Systematic review and meta-analysis of randomised
controlled trials. British Medical Journal, 347, f6234. doi:10.1136/bmj.f6234

Abstract

Objective: To determine whether, and to what extent, fall prevention exercise interventions for older,
community-dwelling people are effective in preventing different types of fall-related injuries.

Data sources: Electronic databases (PubMed, the Cochrane Library,
Embase, and CINAHL) and reference lists of included studies and relevant reviews from inception to July
2013.

Study selection: Randomized controlled trials of fall prevention exercise interventions, targeting older
(>60 years), community-dwelling people and providing quantitative data on injurious falls, serious falls, or
fall-related fractures.

Data synthesis: On the basis of a systematic review of the case definitions used in the selected studies,
we grouped the definitions of injurious falls into more homogeneous categories to allow comparisons of
results across studies and the pooling of data. For each study, we extracted or calculated the rate ratio of
injurious falls. Depending on the available data, a given study could contribute data relevant to one or
more categories of injurious falls. A pooled rate ratio was estimated for each category of injurious falls on
the basis of random effects models.

Results: Seventeen trials involving 4,305 participants were eligible for meta-analysis.
Four categories of falls were identified: all injurious falls, falls resulting in medical care, severe injurious
falls, and falls resulting in fractures. Exercise had a significant effect in all categories, with pooled
estimates of the rate ratios of 0.63
(95% CI 0.51–0.77,10 trials) for all injurious falls, 0.70 (0.54–0.92, 8 trials) for falls resulting in medical
care, 0.57 (0.36–0.90, 7 trials) for
severe injurious falls, and 0.39 (0.22–0.66, 6 trials) for falls resulting in
fractures, but significant heterogeneity was observed among studies of all
injurious falls (I2 = 50%, P = 0.04).

Conclusions: Exercise programs designed to prevent falls in older adults
also seem to prevent injuries caused by falls, including the most severe ones.
Such programs also reduce the rate of falls leading to medical care.

Page 4 of 7

Evidence, Effectiveness, and Clinical Quality
©2014 South University

Hutton, L., Frame, R., Maggo, H., Shirakawa, H., Mulligan, H., Waters, D., & Hale, L. (2009). The
perceptions of physical activity in an elderly population at risk of falling: A focus group study. New
Zealand Journal of Physiotherapy, 37(2), 85–92.
Retrieved from http://physiotherapy.org.nz/assets/Professional-dev/Journal/2009-
July/2009JulMLRoberts

Abstract

This study aimed to develop an understanding of the perceptions that older
adults at risk of falls, and previously involved in organized group exercise, have
of physical activity. By identifying factors that these older adults feel help or
hinder their involvement in physical activity, measures can be taken to enable
optimal participation. Twenty participants aged 68–81 years, recruited from falls prevention exercise
classes, were allocated into five focus groups to discuss their experiences and views of physical activity.
Thematic analysis aligned participants’ views with the transtheoretical model of behavioral change.
Participants voiced a need for education and motivation to develop self-efficacy, to overcome barriers to
involvement and to acknowledge the associated benefits before they could commit to and maintain an
exercise program.

Actions to optimize participation included education about exercise requirements and the benefits to be
gained, improvement of motivation and self-efficacy through health professional support and by promotion
of peer-support initiatives, and continued improvements in quality of and accessibility to community
exercise programs, including the development of appropriate class environments with well-trained leaders
to ensure safety of and suitability for this population.

Page 5 of 7

Evidence, Effectiveness, and Clinical Quality
©2014 South University

Oh, D. H., Park, J. E., Lee, E. S., Oh, S. W., Cho, S. I., Jang, S. N., & Baik, H. W. (2012). Intensive
exercise reduces the fear of additional falls in elderly people: Findings from the Korea falls prevention
study. Korean Journal of Internal Medicine, 27(4), 417–425.

Background/Aims: Falls among older people are a major public health problem and may result in
fracture, medical complications that require hospitalization, and fear of additional falls. Given the
prevalence of falls and the impact of the fear of falling again, reducing the incidence of falls is important to
prevent additional falls. This study analyzed whether exercise programs decrease the fear of future falls
in elderly patients who have fallen previously.

Methods: A randomized controlled study was performed that included 65 elderly community-dwelling
subjects who had fallen in the previous year. Subjects were randomized into two groups, an exercise
group (EG, n = 36) and a control group
(CG, n = 29). The EG participated in three exercise sessions per week for 12
weeks. Muscle strength, balance, agility, flexibility, and muscular endurance were
measured at baseline and after 12 weeks.

Results: After the 12-week exercise program, the subjects in the EG demonstrated remarkable
improvement in their walking speeds, balance (p = 0.003), back strength (p = 0.08), lower extremity
strength (p = 0.004), and flexibility (p < 0.001). When asked whether they were afraid of falling, more participants in the EG than in the CG responded “not at all” or “a little.” Conclusions: The 12-week exercise program described here reduced the fear of falling (p = 0.02). It also improved the balance, flexibility, and muscle strength of the participants and was associated with improved quality of life.

Page 6 of 7

Evidence, Effectiveness, and Clinical Quality
©2014 South University

Sherrington, C., Whitney, J. C., Lord, S. R., Herbert, R. D., Cumming, R. G., &
Close, J. C. T. (2008). Effective exercise for the prevention of falls: A systematic
review and meta-analysis. Journal of the American geriatric Society, 56(12),
2234–2243. Retrieved from
http://www.lpsc.nsw.gov.au/pdf/sherrington%20syst%20rev%2008

Objectives: To determine the effects of exercise on falls prevention in older people and establish
whether particular trial characteristics or components of exercise programs are associated with larger
reductions in falls.

Design: Systematic review with meta-analysis—randomized controlled trials that
compared fall rates in older people who undertook exercise programs with fall rates in those who did not
exercise were included.

Setting: Older people.

Participants: General community and residential care.

Measurements: Fall rates.

Results: The pooled estimate of the effect of exercise was that it reduced the rate of falling by 17% (44
trials with 9,603 participants, RR 50.83, 95% CI 50.75–0.91, P = 0.001, I2 = 62%). The greatest relative
effects of exercise on fall rates (RR 50.58, 95% CI 50.48–0.69, 68% of between-study variability
explained) were seen in programs that included a combination of a higher total dose of exercise (450
hours over the trial period) and challenging balance exercises (exercises conducted while standing, in
which people aimed to stand with their feet closer together or on one leg, minimize use of their hands to
assist, and practice controlled movements of the center of mass) and did not include a walking program.

Conclusion: Exercise can prevent falls in older people. Greater relative effects are seen in programs that
include exercises that challenge balance, use a higher dose of exercise, and do not include a walking
program. Service providers can use these findings to design and implement exercise programs for falls
prevention.

http://www.lpsc.nsw.gov.au/pdf/sherrington%20syst%20rev%2008

Page 7 of 7

Evidence, Effectiveness, and Clinical Quality
©2014 South University

Taylor, D., Hale, L., Schluter, P., Waters, D. L., Binns, E. E., McCracken, H., . . . Wolf, S. L. (2012).
Effectiveness of tai chi as a community-based falls prevention intervention: A randomized controlled trial.
Journal of the American Geriatrics Society, 60(5), 841–848.

Objectives: To compare the effectiveness of tai chi and low-level exercise in reducing falls in older
adults; to determine whether mobility, balance, and lower
limb strength improves and whether higher doses of tai chi result in greater
effect.

Design: Randomized controlled trial.

Setting: Eleven sites throughout New Zealand.

Participants: Six hundred eighty-four community-residing older adults (mean
age 74.5; 73% female) with at least one fall risk factor.

Intervention: Tai chi once a week (TC1) (n = 233); tai chi twice a week (TC2) (n
= 220), or a low-level exercise program control group (LLE) (n = 231) for 20 weeks.

Measurements: The number of falls was ascertained according to monthly falls calendars. Mobility
(Timed-Up and-Go test), balance (step test), and lower limb
strength (chair stand test) were assessed.

Results: The adjusted IRR for falls was not significantly different between the TC1 and LLE groups (IRR
= 1.05, 95% CI = 0.83–1.33, P = .70) or between the TC2 and LLE groups (IRR = 0.88, 95% CI = 0.68–
1.16, P = .37). Adjusted multilevel mixed-effects
Poisson regression showed a significant reduction in the logarithmic mean fall rate of
0.050 (95% CI = 0.064–0.037, P < .001) per month for all groups. Multilevel fixed-effect analyses indicated improvements in balance (P < .001 right and left leg) and lower limb strength (P < .001) but not mobility (P = .54) in all groups over time, with no differences between the groups (P = .37 [right leg], P = .66 [left leg], P = .21, and P = .44, respectively). Conclusion: There was no difference in falls rates between the groups, with falls reducing similarly (a mean falls rate reduction of 58%) over the 17-month follow-up period. Strength and balance improved similarly in all groups over time.