Authors' objectives: Falls are the most common safety incident reported by acute hospitals. The National Institute of Health and Care Excellence recommends multifactorial falls risk assessment and tailored interventions, but implementation is variable. Inpatient falls are the most common safety incident reported by acute hospitals and can cause both physical and non-physical harm. The National Institute of Health and Care Excellence (NICE) guideline on falls in older people recommends a multifactorial falls risk assessment (MFRA) and interventions tailored to address the patient’s identified risk factors for all inpatients aged 65 years and older, or 50–64 years and judged to be at higher risk of falling due to an underlying condition. This approach is estimated to reduce the incidence of inpatient falls by 25–30%. However, there is substantial unexplained variation between hospitals in adherence to this guideline. Use secondary data to develop a theory that explains what supports and constrains routine use of MFRA and falls prevention interventions. Refine the theory through mixed method data collection across three acute hospital Trusts. Translate the theory into guidance to support MFRA and prevention and, in turn, adherence to the NICE guideline.

Authors' results and conclusions: Seventy-eight studies were used for theory construction and 50 for theory testing. Four theories were explored. (1) Leadership: wards had falls link practitioners but authority to allocate resources for falls prevention resided with senior nurses. (2) Shared responsibility: a key falls prevention strategy was patient supervision. This fell to nursing staff, constraining the extent to which responsibility for falls prevention could be shared. (3) Facilitation: assessments were consistently documented but workload pressures could reduce this to a tick-box exercise. Assessment items varied. While individual patient risk factors were identified, patients were categorised as high or low risk to determine who should receive supervision. (4) Patient participation: nursing staff lacked time to explain to patients their falls risks or how to prevent themselves from falling, although other staff could do so. Sensitive communication could prevent patients taking actions that increase their risk of falling. (1) Leadership: There should be a clear distinction between senior nurses’ roles and falls link practitioners in relation to falls prevention; (2) shared responsibility: Trusts should consider how processes and systems, including the electronic health record, can be revised to better support a multidisciplinary approach, and alternatives to patient supervision should be considered; (3) facilitation: Trusts should consider how to reduce documentation burden and avoid tick-box responses, and ensure items included in the falls risk assessment tools align with guidance. Falls risk assessment tools and falls care plans should be presented as tools to support practice, rather than something to be audited; (4) patient participation: Trusts should consider how they can ensure patients receive individualised information about risks and preventing falls and provide staff with guidance on brief but sensitive ways to talk with patients to reduce the likelihood of actions that increase their risk of falling. Implications for practice (1) Leadership: There should be a clear distinction between senior nurses’ roles and falls link practitioners in relation to fall prevention; (2) shared responsibility: Trusts should consider how processes and systems, including EHRs, can be revised to better support a multidisciplinary approach, and alternatives to patient supervision should be considered; (3) facilitation: Trusts should consider how to reduce documentation burden and avoid tick-box responses and ensure that items included in the falls risk assessment tools align with guidance. Falls risk assessment tools and falls care plans should be presented as tools to support practice, rather than something to be audited; (4) patient participation: Trusts should consider how they can ensure patients receive individualised information about risks and preventing falls and provide staff with guidance on brief but sensitive ways to talk with patients to reduce the likelihood of actions that increase their risk of falling.

Authors' recommendations: Future research on falls risk assessment and prevention should include those with cognitive impairment and patients who do not speak the main language of the country in which the research is taking place: development and mixed method and economic evaluation of interventions to support multidisciplinary teams to undertake, and involve patients in, MFRA and selection and delivery of tailored interventions mixed method and economic evaluations of cohort bays and one-to-one care, comparing this to tailored alternatives mixed method and economic evaluations of engagement support workers, volunteers, and/or carers to support falls prevention.

Authors' methods: Realist review and multisite case study. (1) Systematic searches to identify stakeholders’ theories, tested using empirical data from primary studies. Review of falls prevention policies of acute Trusts. (2) Theory testing and refinement through observation, staff interviews (n = 50), patient and carer interviews (n = 31) and record review (n = 60). Three Trusts, one orthopaedic and one older person ward in each. Within the realist review, we completed synthesis for only two theories. We could not access patient records before observations, preventing assessment of whether care plans were enacted. Throughout the study, we were supported by DW, the lay member of the project management group, and the Lay Research Group (a group of service users and carers who had either fallen themselves or cared for someone who fell in hospital). We first undertook a realist review. In Phase 1, systematic searches were undertaken for commentary-type articles, studies mentioning theories/conceptual models for falls risk assessment, and systematic reviews. Additionally, a search of professional/trade journals and an advanced Google search were undertaken. Titles, abstracts and full texts were screened for relevance. Data about contexts, mechanisms and outcomes were extracted from included papers, and referenced substantive theories were noted. Data were summarised in matrices, used to construct context mechanism outcome configurations (CMOcs). To determine which CMOcs should be taken forward for testing in Phase 2, the Lay Research Group and Study Steering Committee (SSC) (comprised of clinicians, academics, and a lay member, with expertise including falls prevention, risk assessment, patient safety and implementation science) ranked them, giving top rankings to statements they believed most likely to work in practice. The Lay Research Group was also asked to highly rank statements likely to have greatest impact for patients and carers. In Phase 2 of the realist review, systematic searches for the four concepts ranked highly by both the Lay Research Group and SSC were conducted across a range of databases. Titles, abstracts and full texts were screened for relevance. In Phase 3 of the realist review, data extraction was conducted using NVivo, coding sections of manuscripts to facilitate theory testing. Researchers analysed two CMOcs: one focused on implementation – facilitation – and one focused on falls risk reduction – patient participation. Narrative summaries were written and used to refine the initial CMOcs. Included texts were appraised using the mixed methods appraisal tool (MMAT). To assess strength of the body of evidence for the refined CMOcs, we used Grades of Recommendation, Assessment, Development and Evaluation-Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual). As an additional source of evidence, we undertook an advanced Google search for the policies of 25 acute Trusts regarding falls risk assessment and prevention. We assessed adherence of these policies to the NICE guideline on falls in older people by checking whether a falls risk prediction tool was recommended; whether the approach recommended involved tailoring interventions to patients’ individual risk factors; and by looking for specific elements of the assessments undertaken (such as whether continence and cognitive impairment are assessed), as specified by NICE and captured in the National Audit of Inpatient Falls (NAIF). We then conducted a multisite case study to further refine the theories across three NHS acute Trusts in England. Trusts were selected to ensure variation in key indicators in the NAIF and in health IT, and to include both teaching and district general hospitals. In each Trust, we collected data in one older person ward and one orthopaedic ward. Data were collected through 251.25 hours of ethnographic observations of falls prevention practices, interviews with staff (n = 50), patients (n = 28) and carers (n = 3), and a review of patient clinical records (n = 60). We also received routinely collected data on the number of falls and falls-related harms. The Lay Research Group contributed to the development of the observation protocol and interview topic guides for patients and carers. Observations took place at different times of day, including night shifts, and different days of the week, including weekends. The record review extracted data on (1) whether a falls risk assessment was completed for the patient on admission and within 6 hours; (2) whether a care plan was documented for the patient and if this was completed on a day or night shift; and (3) whether the care plan was updated and if updates were completed on a day or night shift. Qualitative data analysis followed the steps of framework analysis. The Lay Research Group contributed, providing a patient perspective. Descriptive statistics were produced for the record review data, broken down by ward. Narratives were written and used to refine the CMOcs. Online presentations at each case site acted as a form of respondent validation and an opportunity to gather participants’ perspectives on the implications of the research for practice. A limitation of the review is that we were only able to complete data synthesis for two CMOcs. Limitations of the case study are that our observations focused on nursing staff, as they were most present on the wards, and we were unable to access patient records prior to observations, preventing assessment of whether care plans were enacted. Additionally, we did not manage to recruit patient participants who did not speak English; while we had information sheets translated into the three most spoken non-English languages across the case sites, all patients we met could speak English.

Project Status: Completed

URL for project: https://www.journalslibrary.nihr.ac.uk/programmes/hsdr/NIHR129488

Year Published: 2024

URL for published report: https://www.journalslibrary.nihr.ac.uk/hsdr/JWQC5771

URL for additional information: English

English language abstract: An English language summary is available

Publication Type: Full HTA

Country: England, United Kingdom

DOI: 10.3310/JWQC5771

Organisation Name: NIHR Health Services and Delivery Research programme

Contact Address: NIHR Journals Library, National Institute for Health and Care Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK

Contact Name: journals.library@nihr.ac.uk

Contact Email: journals.library@nihr.ac.uk