Implementing recommended falls prevention practices for older patients in hospitals in England: a realist evaluation

<b>Objective: </b>To explore why there is variation in implementation of multifactorial falls prevention practices that are recommended to reduce falls risks for older patients in hospital. <br/><br/><b>Design: </b>Mixed method, realist evaluation. <br/><br/><b>Setting:</b> Three older person and three orthopaedic wards in acute hospitals in England. <br/><br/><b>Participants: </b>Health care professionals including nurses, therapists, and doctors (n=40), and patients aged 65 and over, and carers (n=31).<br/><br/><b>Intervention: </b>We examined mechanisms hypothesised to underpin implementation of multifactorial falls risk assessment and multidomain, personalised prevention plans. <br/><br/><b>Primary and secondary outcome measures: </b>We developed explanation detailing how contextual factors supported or constrained implementation of recommended falls prevention practices. <br/><br/><b>Results: </b>Nurses led delivery of falls risk assessment and prevention planning using their organisation’s Electronic Health Records (EHR) to guide and document these practices. Implementation of recommended practices was influenced by (1) organisational EHR systems that differed in falls risk assessment items they included, (2) competing priorities on nurse time that could reduce falls risk assessment to a tick box exercise, encourage ‘blanket’ rather than tailored interventions, and that constrained nurse time with patients to personalise prevention plans, and (3) established but not recommended falls prevention practices, such as risk screening, that focused multidisciplinary communication on patients screened as at high risk of falls and that emphasised nursing, rather than MDT, responsibility for preventing falls through constant patient supervision.<br/><br/><b>Conclusions: </b>To promote consistent delivery of multifactorial falls prevention practices, and to help ease the nursing burden, organisations should consider how electronic systems and established ward-based practices can be reconfigured to support greater multidisciplinary staff and patient and carer involvement in modification of individual falls risks.<br/>