A realist evaluation of multifactorial falls risk assessment and prevention practices

Abstract

Abstract Background: Multifactorial falls risk assessments (MFRAs) and personalised interventions are recommended practices to reduce risk of falls in hospitals, but there is variation in implementation at practice level, reasons for which have not been explored. The aim of this study was to explore reasons for the variation. Methods: Realist evaluation was used to interrogate how, why and in what contexts falls prevention practices are implemented. Four realist hypotheses about delivery of MFRAs and personalised interventions labelled: Falls Leadership, Facilitation via MFRA tools, Shared responsibility, and Patient participation were tested. Testing was conducted via a multi-site case study in three acute hospitals in older person and orthopaedic wards. Data collection included ethnographic observations (251.25 hours); interviews with staff (n=50), patients and carers aged over 65 (n=31); and clinical record review (n=60). Results: MFRA tools were embedded in nursing practice, located in the Electronic Health Record. Nurses reported that these tools prompted assessment of individual falls risk factors and clinical records indicated that MFRAs and prevention plans were documented with consistency. However, assessment items varied between MFRA tools and competing priorities on nurse time could reduce tool use to a tick-box exercise. Patient supervision, delivered with different levels of intensity by nursing staff, was a key falls prevention intervention. Supervision appeared to constrain the extent to which responsibility for preventing falls was felt to be shared within multidisciplinary teams. Staff interactional skills such as conveying sincerity encouraged patient participation in interventions and understanding patient perspectives enabled personalisation of care in ways that supported their engagement in safety efforts; non-nursing staff and carers helped surface patient perspectives. Conclusions: Organisational policy reflects the MFRA approach. However, to promote reliable delivery of multidisciplinary, personalised interventions, and to help ease the nursing burden, organisations should consider how systems can support clinical teams to work together cohesively to modify individual falls risk factors, and drawing on non-nursing staff and carers to help personalise care in ways that encourage patient participation and engagement in safety efforts.