Falls_Prevention

The aim of this assignment is to analyse the process of risk assessment and risk management. In order to achieve this The Falls Risk Assessment Tool (FRAT) (Nandy et al 2004) will be applied to the fictional character Ron Wayman from Wessex Bay. The assignment will then discuss how the identified risks could be managed through effective interprofessional working. In doing this the key issues that will be discussed include the efficacy of the FRAT, ethical issues involved in risk management; and issues in collaborating across professional boundaries to promote effective team working as part of a risk management strategy. Before commencing this assignment it is necessary to consider what we mean by the term risk. Roberts (2002) defines risk as the possibility of injury, harm or loss. Douglas (1992 cited in Titterton 2005) asserts that risk is a social construct, arguing that perceptions of risk vary between societies and between individuals. This is significant for professionals involved in managing risk within health or social care as service users, carers and the interprofessional team may perceive and identify risks differently. The client to be discussed within this assignment is Ron, a 76 year old gentleman with a diagnosis of COPD living in the community who is housebound, reliant on constant oxygen with poor mobility and a history of falling (Appendix 1). Reading the case study it is clear Ron has complex health and social needs and a host of risks including malnutrition, depression and falls. For the purpose of this assignment the risk of falls will be considered. A fall can be defined as “unexpected events in which a person comes to the ground or other lower level” (Lamb et al, 2005 p1618) Falls within elderly people are a significant health issue with 1.57 million people aged over 65 having three or more falls each year. (Nazarko 2005) The implications of falls for Ron are likely to be substantial. Falls are the most common cause of accidental death in older people and every year approximately 70,000 people fracture their hips (Christodolou et al , 2003). After a fall the individual may be unable to get up off the floor or call for assistance. If a long “lie” follows, hypothermia, dehydration, pressure sores, rhabdomyolosis and pneumonia can occur (Edelberg, 2002). Furthermore, the consequences of falls are often far reaching psychologically, resulting in fear, anxiety, depression and isolation. Repeated falls may result in an increasing dependence on health and social care services and precipitate admission to long term care. (Tinetti 2003) There has been a growing focus in Policy and service provision on the assessment of falls with a view to prevention. This has been formalised by the development of The NICE guidelines on falls (2004) and The National Service Framework for older people (DoH 2001). Risk management is a shared feature of all Health regulatory bodies and consequently health professionals have a duty to maintain the safety of their patients. The NMC (2008) states that all nurses must act to identify and minimise risk to patients and clients’. Falls prevention clearly falls within this duty. The first step in developing a risk strategy is to undertake a risk assessment. The Health and Safety Executive (2006)) describes risk assessment as a structured procedure which involves the correct identification of hazards and an estimation of the risks arising from them. Risk assessment assists staff in targeting the patient at risk and in choosing appropriate strategies to manage that risk. (Moore et al 1996) NICE (2004) recommend the use of a falls risk assessment tool, but no specific one is identified. For the purpose of this assignment the FRAT will be used. This tool is designed to be used by community staff to identify if a person is at risk of falls, encompassing five questions shown by research to be independent falls risk factors; history of falling in the previous year, four or more prescribed medications, diagnosis of stroke/Parkinson's disease, reported problems with balance and inability to rise from a chair without using arms. Positive identification of at least three of these factors identifies the individual as being at high risk of falls and suggests further action is required. This tool was chosen as it has a National background, being the most frequently used by specialist falls services within the United Kingdom. (Gates et al 2006) It is user friendly being quick and easy to use, with no specialist training required. Consequently it can be easily incorporated into other assessments such as primary care health checks and can be used opportunistically during GP consultations. Primary care professionals, physiotherapists and occupational therapists who piloted the tool found it easy to use. (Nandy et al 2004 ) This is significant as tools which are lengthy or complicated are likely to have low adherence. (Oliver 2009). The FRAT was specifically designed for use in the community, in the absence of a validated assessment tool of an older persons risk of falling that could be applied in primary care. Whilst other falls risk assessment tools exist including the Falls Risk Assessment Scale for the Elderly (FRASE) (Cannard 1996) they have been validated in hospitals/care homes and as proposed by Cooper et al (2003) caution is needed in generalization to other clinical settings. The FRAT is evidence based, being formulated on a systematic review of community based prospective studies identifying risk factors for falling. Following its development, research was conducted into its validity and it was concluded that the tool was useful in identifying patients who would benefit from further interventions. (Nandy et al 2004 ) However, on examination there is a need to be cautious about its efficacy. To be effective a risk assessment tool should have predictive validity; it should be able to predict those patients who go on to fall (sensitivity) and those who do not (specificity). (Oliver 2009) Research conducted by Nandy et al (2004) demonstrated that the FRAT had a high specifity of 0.92% but a sensitivity of only 0.59%. Consequently a criticism of the tool is that in view of its low sensitivity it may tend to under predict the incidence of falls, meaning potential fallers are not targeted for interventions. Assessing risk using preordained scales can reduce the process of decision making to a ‘numbers game’, where important variable qualitative elements may be overlooked. Consequently risk assessment tools should not be used in isolation and clinical judgement is required in their use and in interpreting their results. Moore et al (1996) compared falls risk assessment tools to clinical judgement as a way of assessing falls risk, finding that only 80% of falls could be predicted, concluding that the combined use of a risk assessment tool and clinical judgment was the most appropriate way of assessing risk. The FRAT must be completed with Ron. As asserted by Parsloe (1999) risk assessment is a huge invasion of privacy for which the professional must seek consent. The completed FRAT (Appendix 2) indicates that Ron is at high risk of falls, having risk factors of; a previous fall, inability to rise from a chair without using arms (assumed from his limited mobility), balance/gait problems and being on four or medications (which we can assume in view of his age, chronic health condition and pharmacotherapy). Having identified Ron as at risk, the professional must ensure preventative measures are implemented. Simply recording the risk and taking no further action is a failure to fulfil their duty of care and can be considered negligence. Risk assessment is meaningless without action and a danger with completing risk prediction tools is that it can become an end in itself. (Oliver , 2009) A further advantage of the FRAT is that it recognises this, outlining actions for reducing risk factors. Risk management is defined by Gurney (2000 p300) as “processes used by organisations to minimise negative outcomes which can arise in the delivery of welfare services.” However, a problem with this definition is that it locates responsibility for managing risk with the organisation alone, ignoring the role of the service user. Successful risk management stems from empowerment and involving the service user in all stages of the process. (Morgan 2001) NICE (2004) recommend that as part of a falls risk strategy individuals such as Ron should be given information regarding the risk of falls, their preventable nature and the physical and psychological benefits of modifying risk factors; e.g. increased independence and reduced likelihood of hospital admissions which we can see are priorities for him. By providing individuals with unbiased information, health professionals can help to increase patients autonomy enabling them to make their own fully informed decisions about risk. As stipulated by the DoH (2007) a risk strategy should be person centred, Ron’s views and values with regards to falls risk should be addressed. The falls prevention plan should be built around the changes Ron is willing to make. Allowing an individual control over their situation promotes confidence and self belief which are crucial to effective self management (Burckhardt, 2005) Research conducted by the University of Southampton demonstrated that engaging older persons in decisions about falls prevention improves acceptance and concordance with recommendations and referrals. (Yardley et al, 2007) Ron’s daughter Melanie would also need to be involved in the decision making process. The DoH (2007) states that where carers are involved they are likely to be key persons in managing the risks identified. Whilst the professionals duty of care is to Ron it is evident that his level of functioning is dependent on input from his daughter, and under the Carers Recognition Act (DoH 1995) she should be offered support and an assessment of needs. However, it must be recognised that Ron has a right to confidentiality, and whilst we can assume that Melanie is his main carer his consent must be formally obtained before information is disclosed. There is no single professional group that has the expertise to tackle all the risk factors for Ron. As outlined by DoH (2001) an effective falls prevention plan will require the skills available from a range of professionals. Hornby (2000) supports this and states that to provide holistic care there need to be a vision extending beyond the remit of a single professional and one that encompasses all the different professionals who may contribute to meeting the clients needs. By working together professionals can provide a more seamless and integrated approach to complex problems such as falls. Interprofessional working involves interactions between two or more professionals and is defined as a “collaborative venture in which those involved share the common purpose of developing mutually agreed goals achieved through agreed plans and monitored and according to agreed procedures.” Effective collaboration between Ron, Melanie and a number of professionals will thus be essential for managing Ron’s risks. In order to facilitate this the single assessment process (SAP) will be used. The SAP is outlined in the National Service Framework for older persons (DoH 2001) and requires agencies and professionals to work together at all levels to ensure the effective and coordinated assessment of need and planning of care. The SAP can be seen to be person centred placing the individual at the heart of the process and requiring professionals to work in partnership with individuals and their families. Using the single assessment process following the initial assessment the nurse would need to involve the wider team and refer Ron, with his consent to a number of professionals for specialist assessments. The NMC Code of Conduct (2008) states that the nurse must refer to another practitioner when it is in the best interest of the patient. By referring to other agencies the aim is to create a coordinated network of professionals working collaboratively to assess need across professional boundaries. For this to be effective the professional must be well informed of the roles and boundaries of other professionals, otherwise professionals who could make a valuable contribution may not be engaged. (Hornby 2000) Respect and trust is essential and professionals must recognise not only the value of their own contribution but value the skills and knowledge that other professionals bring. (Crawford and Walker 2007) The DoH (2001) recommend that falls prevention programmes should focus on the individual’s particular risk factors, and tailor an intervention to each of these. In view of Ron’s polypharmacy a medication review should be undertaken, Ron’s GP would need to be approached. If an individual is taking polypharmacy their risk of falls increases significantly. Furthermore certain medications are associated with an increased risk of falling; including sedatives and antidepressants which can cause confusion and sedation, and anti-hypertensives and diuretics which may give rise to postural hypotension and contribute to a fall when the person mobilises. (Unsworth 2003) Ron’s age means he is likely to be more vulnerable to the effects of medications and may respond to lower doses. Ageing effects renal and hepatic function, affecting the way drugs are absorbed, metabolised and excreted (Ewing 2002) The GP should discuss discontinuing or reducing medications with Ron and look at alternative methods of managing symptoms. For example if reducing psychotropic medications such as antidepressants non-pharmacological methods of improving mood could be suggested. This may also require collaboration with specialist mental health services. Consideration should be given to the consequences of reducing or stopping these medications, e.g. on his health or quality of life. This is significant as whilst interventions maybe implemented on the basis of beneficence they should also consider the principle of non-maleficence. (Beauchamp et al 1989)) Reducing his risk of falling needs to be balanced against possible consequences on his mental health. Ron is at increased risk of falling due to problems with balance/gait and reduced muscle strength probably resulting from both the ageing process and his restricted mobility due to his shortness of breath. Muscle wastage of the thighs means the knees are less stable and give in, whilst calf muscle wastage means the individual doesn’t lift their feet, shuffles and is more likely to trip. In view of this a referral should be made to a physiotherapist. Physiotherapists can aid in problems of mobility, gait or posture, through the assessment of suitable footwear, prescription of walking aids, low intensity leg strengthening and weight bearing exercises, as well as gait balance and transfer training which are individually prescribed and monitored (Perdue 2003). Close liaison will be required with the community occupational therapist. Occupational therapists consider how the individual functions in his day to day environment and work collaboratively with the individual to promote independence. To ensure functional movements and activities of daily living can be carried out in a safer way the OT may suggest adaptive equipment such as grab rails or adjustments to bed/chair height. Having completed an environmental hazards assessment the OT may suggest the removal of trip hazards such as loose rugs or furniture. Ron may also need to be given advice on how to manoeuvre safely in view of oxygen tubing which is likely to be a significant hazard. Attempts to modify environmental risk factors within Ron’s home need to be done sensitively, the occupational therapist will need to gain his trust and consent. In line with ethical principle of autonomy Ron has the right to refuse adaptations to his home especially in view of potential financial costs and the professional must accept the individual’s preferences and their right to keep their home as it is, despite the risk (Perdue 2003). Other professionals may consequently need to be involved. Problems identified by the OT may necessitate the involvement of a social worker to implement a care package to reduce risks associated with carrying out ADL’s. A dietician may need to be involved in view of Ron’s poor dietary intake which is suggested by his reluctance to prepare meals and may be exacerbating his risk of falling. As found by Stratton (2003) malnutrition can result in reduced fat, lean body mass, muscle strength and fatigue increasing the risk of falls. For clients such as Ron, needing the help of many practitioners from different teams and agencies at one time, interprofessional working needs to be coordinated to ensure that each person’s efforts have a mutually reinforcing effect or coordination for care synergy. Ovretveit (1997) suggests that one way of tackling this is for one person to act as a case manager so that each professional is aware of what others are doing, and can gage input accordingly. The community modern matron may be best placed to facilitate this role in view of Ron’s long term health condition, as risk assessment should be incorporated within the general holistic assessment of Ron’s needs and cannot be separated from them. Effective communication is essential for interprofessional collaboration and consequently the management of risk. The SAP facilitates this by providing a single document for all agencies to use that travels with the individual through his contact with the health and social care system, thus facilitating information sharing between professionals. (Swan 2005) Molyneux (2001) states that the implementation of interprofessional single patient record enhances communication, collaborative practice and patient care. Uniprofessional records can be dangerous as the absence of a vital piece of information held in a separate part of the health record may result in an adverse effect for the patient. As recognised by Swann (2005) to promote effective communication in the SAP common terminology for care processes, needs and outcomes need to be established. Barrett et al (2005) identify that language barriers exist between professions. Many professionals use obscure jargon inaccessible to those outside the discipline. Terms may have different meanings and entail differing responses in different disciplines. Unless professions are able to communicate effectively integrated care can not occur. Using the single assessment process, assessment information and referrals for Ron will culminate in the development of a detailed care plan. This will identify the common objective, rationale and interventions, stipulating areas of responsibility i.e. who is going to do what and when. This is vital to ensure each professionals work is coordinated towards achieving the same agreed goal and avoids duplication or omissions that may be to the detriment of the service user. (Day 2006) Allen (2002) States that a danger exists in interprofessional working where roles overlap and can become blurred that everyone assumes someone else is responsible for carrying out agreed actions resulting in gaps in service and harm to the service user. Whilst the SAP can be seen to enhance interprofessional collaboration a number of potential obstacles may impair interprofessional approach to managing Ron’s risks. Differences in professional culture need to be considered (Hudson (2002). Each profession is built on different beliefs and values and may consequently have difference perspective on Ron’s risks. For example a social worker may place value on the individual’s autonomy whereas the GP may focus on preserving physical health. These may present sources of conflict and hinder effective interprofessional working. However, differences do not have to be negative. Through regular meetings and opportunities to openly communicate beliefs, professionals may discover new perspectives which will benefit themselves and the client (Irvine et al 2002). In formulating a falls prevention plan for Ron it must be recognised that his risks may change as by definition, dynamic factors such as his physical strength/condition linked to exacerbations of his COPD fluctuate in their contribution to the overall risk. The DoH (2007) states that given the fluidity of risk there should be an established procedure to formally review the assessment of risk at regular intervals. Monitoring and formal review are incorporated into the single assessment process to ensure outcomes are achieved and interventions are appropriate. Having developed a falls prevention plan Ron may chose not to follow the risk advice. When this occurs it is important to recognise that older people who have capacity have the same rights as anyone to make unwise decisions and should be allowed to take risks. Professionals may have concerns that this may conflict with their duty of care and result in claims of negligence. However, an individual who has the mental capacity to make a decision, and chooses voluntarily to live with a level of risk, is treated by law as having consented to the risk and so there will be no breach of the duty of care. If this is the case the basis on which decisions were made and interventions offered must be clearly documented so any course of action maybe properly explained and justified. (Roberts 2002) In conclusion we must recognise that whilst risk can be minimised through effective collaboration between Ron, Melanie and the interprofessional team it cannot be eliminated. There is a danger that a risk-averse approach will lead to that person feeling their autonomy has been overridden and to a loss of confidence having implications for quality of life. Where the individual is reluctant to engage in activities to reduce the number of falls per se, an alternative approach could be to focus on interventions to reduce the severity of fall related injuries, e.g. practical advice on how to summon help, providing a lifeline or hip protectors. References Allen, D., Lyne, P. and Griffiths, l., 2002. Studying complex caring interfaces: key issues arising from a study of multi-agency rehabilitative care for people who have suffered a stroke, Journal of Clinical Nursing, 11, 297-305. Barrett, G. and Keeping, C., 2005. The Processes required for effective interprofessional working. In: Barrett, D., Sellman, J., Thomas, J (eds) Interprofessional Working in Health And Social Care. Basingstoke: Palgrove, 18-32. Beauchamp, T. and Childress, J., 1989. Principles of Biomedical Ethics. 3rd ed. Oxford University Press: Oxford. Cannard, G., 1996. Falling Trend. Nursing Times. 92 (2), 36-37. Christodoulou, C., and Cooper, C., 2003. What is osteoporosis'. Postgraduate Medical Journal, 79 (929), 133-8. Cooper, G., 2003. Developing an evidence-based approach to falls risk assessment. Professional Nurse, 19 (1), 19-23. Department of Health, 2001. National Service Framework for Older people. London: DoH. Available from http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4071283.pdf (accessed 15th March 2010) Department of Health, 2007. Independence, choice and risk: a guide to best practice in supported decision making. London: DoH. Available from: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_074775.pdf (accessed 16th March 2010) Day, J.,2006. Interprofessional Working. Cheltenham: Nelson Thornes. Edelberg, H. K., 2002. Evaluation and the management of fall risk in the older adult. Home Health Consultant, 9 (5), 23-29. Gates, S., Smith, L.A., Fisher, J.D. and Lamb, S.E. 2006. Systematic review of accuracy of screening instruments for predicting fall risk among independently living older adults. Journal of Rehabilitation Research and Development, 45 (8), 1105-1116. Gurney, A., 2000. Risk Management. In: Davies. M., ed. The Blackwell Encyclopaedia of Social Work. Oxford:Blackwell, 300. Hornby, s. and Atkins, J., 2000. Collaborative Care: Interprofessional, Interagency and Interpersonal. 2nd ed. Oxford: Blackwell Science. Health and Safety Executive., 2006. Risk Assessment Tools. http://wwwhse.gov.uk/pubns/ing163.pdf. (accessed 20th March 2010) Hudson, B., 2002. Interprofessionality in health and social care: the Achilles heel of partnerships'. Journal of Interprofessional Care, 16, 199-210. Irvine, R., Kerridge, I., McPhee, J. and Freeman, S., 2002. Interprofessionalism and Ethics; consensus or clash of cultures'. Journal of Interprofessional Care, 16, 199-210. Lamb, S.E., Becker, C. and Jorstad-Stein., 2005 on behalf of ProFaNE. Development of a common outcome data for fall injury prevention trials: The ProFANE consensus. Journal American Geriatric Society, 53 (9), 1618-22. Molyneux, J., 2001. Interprofessional team working: what makes teams work well'. Journal On Interprofessional Care, 15 (1), 19-35. Nandy, S., Parsons, S., Cryer, C. et al., 2004. Development and preliminary examination of the predictive validity of the Falls Risk Assessment Tool (FRAT) for use in primary care. Journal of Public Health, 26 (2), 138-143. Nazarko, L., 2005. Reducing the risk of falls in older people. Nursing and Residential Care, 7 (2), 67-70. National Institute for Health and Clinical Excellence., 2004. Falls: the assessment and prevention of falls in older people. Clinical Guideline 21. NIHCE: London. Moore, T., Martin, J. and Stonehouse, J., 1996. Predicting falls: risk assessment tool versus clinical judgement. Perspectives, 20 (1), 8-11. Morgan, S., 2001. Assessing and Managing Risk: Practitioners Handbook. Brighton: Pavilion. Nursing and Midwifery Council., 2008. Code of Conduct. London: Nursing and Midwifery Council. Available from http://www.nmc-uk.org/aArticleID=3056 (accessed 20th March 2010) Oliver, D. and Healey, F., 2009. Falls Prediction tools for hospital inpatients: do they work'. Nursing Times, 105 (7), 18-21. Ovretveit, J., Mathias, P. and Thompson, T., 1997. Interprofessional Working for Health and Social Care. Basingstoke: Palgrave. Parsloe, P.,1999. Introduction. In Parsloe, P., ed. Risk Assessment in Social Care and Social Work, Research Highlights in Social work, No. 36. London: Jessica Kingsley. Perdue, C., 2003. Falls in older people:taking a multidisciplinary approach. Nursing Times, 99 (31), 28-31. Titterton, M., 2005. Risk and risk taking in health and social care. London: Jessica Kingsley Publishers. Swann, J., 2005. The Single Assessment Process: an overview. Nursing and Residential Care, 7 (2), 84-87. Tinetti, M. E., 2003. Clinical Practice: Preventing falls in elderly people. New England Journal of Medicine, 348, 42-49. Yardley, L., Beyer, N., Hauer, K. et al., 2007. Recommendations for promoting the engagement of older people in activities to prevent falls. Quality and Safety in Healthcare, 16 (3), 230-234. The aim of this assignment is to analyse the process of risk assessment and risk management. In order to achieve this The Falls Risk Assessment Tool (FRAT) (Nandy et al 2004) will be applied to the fictional character Ron Wayman from Wessex Bay. The assignment will then discuss how the identified risks could be managed through effective interprofessional working. In doing this the key issues that will be discussed include the efficacy of the FRAT, ethical issues involved in risk management; and issues in collaborating across professional boundaries to promote effective team working as part of a risk management strategy. Before commencing this assignment it is necessary to consider what we mean by the term risk. Roberts (2002) defines risk as the possibility of injury, harm or loss. Douglas (1992 cited in Titterton 2005) asserts that risk is a social construct, arguing that perceptions of risk vary between societies and between individuals. This is significant for professionals involved in managing risk within health or social care as service users, carers and the interprofessional team may perceive and identify risks differently. The client to be discussed within this assignment is Ron, a 76 year old gentleman with a diagnosis of COPD living in the community who is housebound, reliant on constant oxygen with poor mobility and a history of falling (Appendix 1). Reading the case study it is clear Ron has complex health and social needs and a host of risks including malnutrition, depression and falls. For the purpose of this assignment the risk of falls will be considered. A fall can be defined as “unexpected events in which a person comes to the ground or other lower level” (Lamb et al, 2005 p1618) Falls within elderly people are a significant health issue with 1.57 million people aged over 65 having three or more falls each year. (Nazarko 2005) The implications of falls for Ron are likely to be substantial. Falls are the most common cause of accidental death in older people and every year approximately 70,000 people fracture their hips (Christodolou et al , 2003). After a fall the individual may be unable to get up off the floor or call for assistance. If a long “lie” follows, hypothermia, dehydration, pressure sores, rhabdomyolosis and pneumonia can occur (Edelberg, 2002). Furthermore, the consequences of falls are often far reaching psychologically, resulting in fear, anxiety, depression and isolation. Repeated falls may result in an increasing dependence on health and social care services and precipitate admission to long term care. (Tinetti 2003) There has been a growing focus in Policy and service provision on the assessment of falls with a view to prevention. This has been formalised by the development of The NICE guidelines on falls (2004) and The National Service Framework for older people (DoH 2001). Risk management is a shared feature of all Health regulatory bodies and consequently health professionals have a duty to maintain the safety of their patients. The NMC (2008) states that all nurses must act to identify and minimise risk to patients and clients’. Falls prevention clearly falls within this duty. The first step in developing a risk strategy is to undertake a risk assessment. The Health and Safety Executive (2006)) describes risk assessment as a structured procedure which involves the correct identification of hazards and an estimation of the risks arising from them. Risk assessment assists staff in targeting the patient at risk and in choosing appropriate strategies to manage that risk. (Moore et al 1996) NICE (2004) recommend the use of a falls risk assessment tool, but no specific one is identified. For the purpose of this assignment the FRAT will be used. This tool is designed to be used by community staff to identify if a person is at risk of falls, encompassing five questions shown by research to be independent falls risk factors; history of falling in the previous year, four or more prescribed medications, diagnosis of stroke/Parkinson's disease, reported problems with balance and inability to rise from a chair without using arms. Positive identification of at least three of these factors identifies the individual as being at high risk of falls and suggests further action is required. This tool was chosen as it has a National background, being the most frequently used by specialist falls services within the United Kingdom. (Gates et al 2006) It is user friendly being quick and easy to use, with no specialist training required. Consequently it can be easily incorporated into other assessments such as primary care health checks and can be used opportunistically during GP consultations. Primary care professionals, physiotherapists and occupational therapists who piloted the tool found it easy to use. (Nandy et al 2004 ) This is significant as tools which are lengthy or complicated are likely to have low adherence. (Oliver 2009). The FRAT was specifically designed for use in the community, in the absence of a validated assessment tool of an older persons risk of falling that could be applied in primary care. Whilst other falls risk assessment tools exist including the Falls Risk Assessment Scale for the Elderly (FRASE) (Cannard 1996) they have been validated in hospitals/care homes and as proposed by Cooper et al (2003) caution is needed in generalization to other clinical settings. The FRAT is evidence based, being formulated on a systematic review of community based prospective studies identifying risk factors for falling. Following its development, research was conducted into its validity and it was concluded that the tool was useful in identifying patients who would benefit from further interventions. (Nandy et al 2004 ) However, on examination there is a need to be cautious about its efficacy. To be effective a risk assessment tool should have predictive validity; it should be able to predict those patients who go on to fall (sensitivity) and those who do not (specificity). (Oliver 2009) Research conducted by Nandy et al (2004) demonstrated that the FRAT had a high specifity of 0.92% but a sensitivity of only 0.59%. Consequently a criticism of the tool is that in view of its low sensitivity it may tend to under predict the incidence of falls, meaning potential fallers are not targeted for interventions. Assessing risk using preordained scales can reduce the process of decision making to a ‘numbers game’, where important variable qualitative elements may be overlooked. Consequently risk assessment tools should not be used in isolation and clinical judgement is required in their use and in interpreting their results. Moore et al (1996) compared falls risk assessment tools to clinical judgement as a way of assessing falls risk, finding that only 80% of falls could be predicted, concluding that the combined use of a risk assessment tool and clinical judgment was the most appropriate way of assessing risk. The FRAT must be completed with Ron. As asserted by Parsloe (1999) risk assessment is a huge invasion of privacy for which the professional must seek consent. The completed FRAT (Appendix 2) indicates that Ron is at high risk of falls, having risk factors of; a previous fall, inability to rise from a chair without using arms (assumed from his limited mobility), balance/gait problems and being on four or medications (which we can assume in view of his age, chronic health condition and pharmacotherapy). Having identified Ron as at risk, the professional must ensure preventative measures are implemented. Simply recording the risk and taking no further action is a failure to fulfil their duty of care and can be considered negligence. Risk assessment is meaningless without action and a danger with completing risk prediction tools is that it can become an end in itself. (Oliver , 2009) A further advantage of the FRAT is that it recognises this, outlining actions for reducing risk factors. Risk management is defined by Gurney (2000 p300) as “processes used by organisations to minimise negative outcomes which can arise in the delivery of welfare services.” However, a problem with this definition is that it locates responsibility for managing risk with the organisation alone, ignoring the role of the service user. Successful risk management stems from empowerment and involving the service user in all stages of the process. (Morgan 2001) NICE (2004) recommend that as part of a falls risk strategy individuals such as Ron should be given information regarding the risk of falls, their preventable nature and the physical and psychological benefits of modifying risk factors; e.g. increased independence and reduced likelihood of hospital admissions which we can see are priorities for him. By providing individuals with unbiased information, health professionals can help to increase patients autonomy enabling them to make their own fully informed decisions about risk. As stipulated by the DoH (2007) a risk strategy should be person centred, Ron’s views and values with regards to falls risk should be addressed. The falls prevention plan should be built around the changes Ron is willing to make. Allowing an individual control over their situation promotes confidence and self belief which are crucial to effective self management (Burckhardt, 2005) Research conducted by the University of Southampton demonstrated that engaging older persons in decisions about falls prevention improves acceptance and concordance with recommendations and referrals. (Yardley et al, 2007) Ron’s daughter Melanie would also need to be involved in the decision making process. The DoH (2007) states that where carers are involved they are likely to be key persons in managing the risks identified. Whilst the professionals duty of care is to Ron it is evident that his level of functioning is dependent on input from his daughter, and under the Carers Recognition Act (DoH 1995) she should be offered support and an assessment of needs. However, it must be recognised that Ron has a right to confidentiality, and whilst we can assume that Melanie is his main carer his consent must be formally obtained before information is disclosed. There is no single professional group that has the expertise to tackle all the risk factors for Ron. As outlined by DoH (2001) an effective falls prevention plan will require the skills available from a range of professionals. Hornby (2000) supports this and states that to provide holistic care there need to be a vision extending beyond the remit of a single professional and one that encompasses all the different professionals who may contribute to meeting the clients needs. By working together professionals can provide a more seamless and integrated approach to complex problems such as falls. Interprofessional working involves interactions between two or more professionals and is defined as a “collaborative venture in which those involved share the common purpose of developing mutually agreed goals achieved through agreed plans and monitored and according to agreed procedures.” Effective collaboration between Ron, Melanie and a number of professionals will thus be essential for managing Ron’s risks. In order to facilitate this the single assessment process (SAP) will be used. The SAP is outlined in the National Service Framework for older persons (DoH 2001) and requires agencies and professionals to work together at all levels to ensure the effective and coordinated assessment of need and planning of care. The SAP can be seen to be person centred placing the individual at the heart of the process and requiring professionals to work in partnership with individuals and their families. Using the single assessment process following the initial assessment the nurse would need to involve the wider team and refer Ron, with his consent to a number of professionals for specialist assessments. The NMC Code of Conduct (2008) states that the nurse must refer to another practitioner when it is in the best interest of the patient. By referring to other agencies the aim is to create a coordinated network of professionals working collaboratively to assess need across professional boundaries. For this to be effective the professional must be well informed of the roles and boundaries of other professionals, otherwise professionals who could make a valuable contribution may not be engaged. (Hornby 2000) Respect and trust is essential and professionals must recognise not only the value of their own contribution but value the skills and knowledge that other professionals bring. (Crawford and Walker 2007) The DoH (2001) recommend that falls prevention programmes should focus on the individual’s particular risk factors, and tailor an intervention to each of these. In view of Ron’s polypharmacy a medication review should be undertaken, Ron’s GP would need to be approached. If an individual is taking polypharmacy their risk of falls increases significantly. Furthermore certain medications are associated with an increased risk of falling; including sedatives and antidepressants which can cause confusion and sedation, and anti-hypertensives and diuretics which may give rise to postural hypotension and contribute to a fall when the person mobilises. (Unsworth 2003) Ron’s age means he is likely to be more vulnerable to the effects of medications and may respond to lower doses. Ageing effects renal and hepatic function, affecting the way drugs are absorbed, metabolised and excreted (Ewing 2002) The GP should discuss discontinuing or reducing medications with Ron and look at alternative methods of managing symptoms. For example if reducing psychotropic medications such as antidepressants non-pharmacological methods of improving mood could be suggested. This may also require collaboration with specialist mental health services. Consideration should be given to the consequences of reducing or stopping these medications, e.g. on his health or quality of life. This is significant as whilst interventions maybe implemented on the basis of beneficence they should also consider the principle of non-maleficence. (Beauchamp et al 1989)) Reducing his risk of falling needs to be balanced against possible consequences on his mental health. Ron is at increased risk of falling due to problems with balance/gait and reduced muscle strength probably resulting from both the ageing process and his restricted mobility due to his shortness of breath. Muscle wastage of the thighs means the knees are less stable and give in, whilst calf muscle wastage means the individual doesn’t lift their feet, shuffles and is more likely to trip. In view of this a referral should be made to a physiotherapist. Physiotherapists can aid in problems of mobility, gait or posture, through the assessment of suitable footwear, prescription of walking aids, low intensity leg strengthening and weight bearing exercises, as well as gait balance and transfer training which are individually prescribed and monitored (Perdue 2003). Close liaison will be required with the community occupational therapist. Occupational therapists consider how the individual functions in his day to day environment and work collaboratively with the individual to promote independence. To ensure functional movements and activities of daily living can be carried out in a safer way the OT may suggest adaptive equipment such as grab rails or adjustments to bed/chair height. Having completed an environmental hazards assessment the OT may suggest the removal of trip hazards such as loose rugs or furniture. Ron may also need to be given advice on how to manoeuvre safely in view of oxygen tubing which is likely to be a significant hazard. Attempts to modify environmental risk factors within Ron’s home need to be done sensitively, the occupational therapist will need to gain his trust and consent. In line with ethical principle of autonomy Ron has the right to refuse adaptations to his home especially in view of potential financial costs and the professional must accept the individual’s preferences and their right to keep their home as it is, despite the risk (Perdue 2003). Other professionals may consequently need to be involved. Problems identified by the OT may necessitate the involvement of a social worker to implement a care package to reduce risks associated with carrying out ADL’s. A dietician may need to be involved in view of Ron’s poor dietary intake which is suggested by his reluctance to prepare meals and may be exacerbating his risk of falling. As found by Stratton (2003) malnutrition can result in reduced fat, lean body mass, muscle strength and fatigue increasing the risk of falls. For clients such as Ron, needing the help of many practitioners from different teams and agencies at one time, interprofessional working needs to be coordinated to ensure that each person’s efforts have a mutually reinforcing effect or coordination for care synergy. Ovretveit (1997) suggests that one way of tackling this is for one person to act as a case manager so that each professional is aware of what others are doing, and can gage input accordingly. The community modern matron may be best placed to facilitate this role in view of Ron’s long term health condition, as risk assessment should be incorporated within the general holistic assessment of Ron’s needs and cannot be separated from them. Effective communication is essential for interprofessional collaboration and consequently the management of risk. The SAP facilitates this by providing a single document for all agencies to use that travels with the individual through his contact with the health and social care system, thus facilitating information sharing between professionals. (Swan 2005) Molyneux (2001) states that the implementation of interprofessional single patient record enhances communication, collaborative practice and patient care. Uniprofessional records can be dangerous as the absence of a vital piece of information held in a separate part of the health record may result in an adverse effect for the patient. As recognised by Swann (2005) to promote effective communication in the SAP common terminology for care processes, needs and outcomes need to be established. Barrett et al (2005) identify that language barriers exist between professions. Many professionals use obscure jargon inaccessible to those outside the discipline. Terms may have different meanings and entail differing responses in different disciplines. Unless professions are able to communicate effectively integrated care can not occur. Using the single assessment process, assessment information and referrals for Ron will culminate in the development of a detailed care plan. This will identify the common objective, rationale and interventions, stipulating areas of responsibility i.e. who is going to do what and when. This is vital to ensure each professionals work is coordinated towards achieving the same agreed goal and avoids duplication or omissions that may be to the detriment of the service user. (Day 2006) Allen (2002) States that a danger exists in interprofessional working where roles overlap and can become blurred that everyone assumes someone else is responsible for carrying out agreed actions resulting in gaps in service and harm to the service user. Whilst the SAP can be seen to enhance interprofessional collaboration a number of potential obstacles may impair interprofessional approach to managing Ron’s risks. Differences in professional culture need to be considered (Hudson (2002). Each profession is built on different beliefs and values and may consequently have difference perspective on Ron’s risks. For example a social worker may place value on the individual’s autonomy whereas the GP may focus on preserving physical health. These may present sources of conflict and hinder effective interprofessional working. However, differences do not have to be negative. Through regular meetings and opportunities to openly communicate beliefs, professionals may discover new perspectives which will benefit themselves and the client (Irvine et al 2002). In formulating a falls prevention plan for Ron it must be recognised that his risks may change as by definition, dynamic factors such as his physical strength/condition linked to exacerbations of his COPD fluctuate in their contribution to the overall risk. The DoH (2007) states that given the fluidity of risk there should be an established procedure to formally review the assessment of risk at regular intervals. Monitoring and formal review are incorporated into the single assessment process to ensure outcomes are achieved and interventions are appropriate. Having developed a falls prevention plan Ron may chose not to follow the risk advice. When this occurs it is important to recognise that older people who have capacity have the same rights as anyone to make unwise decisions and should be allowed to take risks. Professionals may have concerns that this may conflict with their duty of care and result in claims of negligence. However, an individual who has the mental capacity to make a decision, and chooses voluntarily to live with a level of risk, is treated by law as having consented to the risk and so there will be no breach of the duty of care. If this is the case the basis on which decisions were made and interventions offered must be clearly documented so any course of action maybe properly explained and justified. (Roberts 2002) In conclusion we must recognise that whilst risk can be minimised through effective collaboration between Ron, Melanie and the interprofessional team it cannot be eliminated. There is a danger that a risk-averse approach will lead to that person feeling their autonomy has been overridden and to a loss of confidence having implications for quality of life. Where the individual is reluctant to engage in activities to reduce the number of falls per se, an alternative approach could be to focus on interventions to reduce the severity of fall related injuries, e.g. practical advice on how to summon help, providing a lifeline or hip protectors. References Allen, D., Lyne, P. and Griffiths, l., 2002. 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