Considerations across multiple stakeholder groups when implementing fall prevention programs in the acute hospital setting: a qualitative study
Multifactorial fall prevention programs can reduce hospital falls but are often not effectively implemented. Stakeholders agree about the importance of preventing hospital falls but identify contextual implementation challenges. Shared responsibility for fall prevention may be a key component to implementation success. Exploring the intersection of diverse stakeholder considerations can guide implementation of hospital fall prevention programs. 

Falls in hospital remain a common and costly patient safety issue for health systems across the world . It is estimated that 30% of hospital falls result in patient physical injury, ranging from minor lacerations to catastrophic injuries such as traumatic brain injuries and death . Falls can result in significant psychological harm for patients and their caregivers , and for hospital staff who may experience stress and anxiety related to fall incidents . For hospitals and the health system, falls with or without injury increase resource requirements and financial burden . The evidence around how to best reduce falls in acute hospitals remains uncertain, with two of the largest clinical trials of fall prevention interventions in hospital showing no effect  . Promising evidence from large trials in subacute settings  and smaller studies in acute settings  provide promising evidence that falls in acute hospital can be reduced through multifactorial fall prevention programs . The most effective programs appear to include patient and health professional fall prevention education  and personalised strategies based on risk, such as rehabilitation, exercise and environmental and system modification . These approaches to hospital fall prevention were strongly recommended in the recent World Falls Guidelines . Nursing, allied health and medical staff are required to deliver these programs . Patient engagement is also necessary in many fall prevention programs where the goal is often to empower patients to take an active role in preventing their own falls, e.g. by consistently calling for assistance to mobilise . Hospital fall prevention programs require appropriate, tailored and consistent implementation to be effective . However, as in many areas of healthcare, an evidence-practice gap exists where interventions shown to be effective in research trials are not always implemented in routine hospital practice . Enhancing the implementation of these programs requires consideration of multiple stakeholder perspectives . There have been studies exploring patient and healthcare professional perspectives on the implementation of hospital falls prevention education based interventions , but no study to-date has explored the intersection of multiple stakeholder opinions when implementing hospital fall prevention programs. Additionally, much of the existing qualitative work exploring hospital fall prevention involves staff and patients from subacute and private hospital settings  which are often less complex than acute settings . The aim of this study was to seek the perspectives of multiple stakeholder groups and explore how these intersect, to answer our research question: Drawing on the perspectives of key stakeholder groups, what should be considered when implementing hospital fall prevention programs in the acute hospital setting? The study was conducted with the objective of providing insights for clinicians, managers and researchers working in acute inpatient settings to address the implementation gap in hospital fall prevention. 

Design Semi-structured interviews and focus groups were conducted with staff, patients and patient family members (when patients themselves were not cognitively appropriate to interview) at two large Australian, acute metropolitan public hospitals. Participants were sampled from wards identified by hospital management as having high patient fall rates as it was thought they would be likely to have staff and patients who have a keen interest in fall prevention in hospital and who would be able to provide valuable insights on the implementation of falls prevention strategies. Participants were sampled purposively for maximum variation in experiences of hospital fall prevention . A qualitative descriptive design  was selected for its utility in producing results as close to the data as possible to practically guide clinical practice . Staff were given the option of participating in individual interviews or focus group interviews depending on preference and feasibility given their clinical workload. Patients and family members were offered individual interviews only to ensure privacy. Recruitment Staff were recruited via flyers displayed in non-patient areas of four wards across the two participating hospitals. Nursing, allied health and medical frontline and management staff were invited to participate. Interested staff contacted a member of the research team and were provided with a Participant Information Sheet (PIS). Following consent, an interview or focus group was arranged. Recruitment of patients and family members occurred via the Nurse Unit Manager (NUM) or physiotherapist of the same four wards. Patients identified by the NUM or physiotherapist as a medium or high fall risk based on clinical judgement and who were sufficiently medically stable to participate in an interview were approached by the NUM. For cognitively impaired patients who met the inclusion criteria, a member of their family was approached to consider participation in an interview instead of the patient. Following an explanation of the study, patients or family members were asked if they would like to meet a member of the research team for further information. If they agreed, a researcher met the patient or family member at the bedside, provided them with a PIS and answered any questions. At least 12 h later, the researcher returned and if the patient or family member consented, an interview time was arranged. Data collection Interviews and focus groups were conducted in-person, onsite at the two hospitals and lasted 20–60 min. A single female member of the research team (CM) with qualitative research experience conducted the staff and patient interviews, and focus groups were facilitated by this same team member plus a second researcher (male or female) (WT or FL). Researchers kept a memo of reflections and ideas about provisional themes . These researchers were nursing and allied health employees of the health district where the data was collected but were not treating any patient participants and did not work in the same department as any staff participants. Interviews and focus groups were audio-recorded, transcribed verbatim by a professional service, and corrected by the lead researcher (CM). Discussion guides for staff and for patients and family members carers were developed by the research team to target concepts most relevant to the research question (see ). All stakeholder groups were asked similar questions so that the intersection of their perspectives could be considered. The framing of the questions differed between the staff and patient/family discussion guides to ensure relevance to the participant. Discussions began by asking about participants’ experiences of falls and fall prevention in hospital, then sought participants views about implementing evidence-based fall prevention programs. Data collection occurred over 9 months and ceased when preliminary data analysis indicated that sufficient staff and patient perspectives and data quality had been obtained to answer the research question, and interviews/focus groups were not yielding significant new information. Data analysis Transcripts from all stakeholder groups were analysed as a combined dataset using an inductive coding approach guided by Sandelowski’s qualitative description analysis . Inductive analysis was used to develop a coding framework that was applied flexibly to all the transcripts and that continued to evolve in response to further data . NVivo software , spreadsheets, documents and tables were used to assist with data analysis. Two researchers (CM and AH) independently analysed and coded three diverse transcripts (a clinician focus group, patient interview and family member interview) and identified early important concepts and patterns. Through discussion, a preliminary inductive coding framework was developed and was applied flexibly to the first three transcripts and an additional transcript from each stakeholder group. Review of this coding in discussion with multiple members of the research team (CM, AH, CS, WT) was used to further refine the framework and this was applied to all transcripts. Reading within and across this coding generated key themes relevant to the research question. Initial themes were discussed by two members of the research team (CM and AH), refined and then presented to the research team (who had diverse, relevant credentials including PhDs and medical, nursing and allied health degrees) with illustrative quotes for critical review, and refinement. Final themes and subthemes were agreed upon and written up narratively. 

Semi-structured interviews and focus groups were conducted with staff, patients and patient family members (when patients themselves were not cognitively appropriate to interview) at two large Australian, acute metropolitan public hospitals. Participants were sampled from wards identified by hospital management as having high patient fall rates as it was thought they would be likely to have staff and patients who have a keen interest in fall prevention in hospital and who would be able to provide valuable insights on the implementation of falls prevention strategies. Participants were sampled purposively for maximum variation in experiences of hospital fall prevention . A qualitative descriptive design  was selected for its utility in producing results as close to the data as possible to practically guide clinical practice . Staff were given the option of participating in individual interviews or focus group interviews depending on preference and feasibility given their clinical workload. Patients and family members were offered individual interviews only to ensure privacy. 

Staff were recruited via flyers displayed in non-patient areas of four wards across the two participating hospitals. Nursing, allied health and medical frontline and management staff were invited to participate. Interested staff contacted a member of the research team and were provided with a Participant Information Sheet (PIS). Following consent, an interview or focus group was arranged. Recruitment of patients and family members occurred via the Nurse Unit Manager (NUM) or physiotherapist of the same four wards. Patients identified by the NUM or physiotherapist as a medium or high fall risk based on clinical judgement and who were sufficiently medically stable to participate in an interview were approached by the NUM. For cognitively impaired patients who met the inclusion criteria, a member of their family was approached to consider participation in an interview instead of the patient. Following an explanation of the study, patients or family members were asked if they would like to meet a member of the research team for further information. If they agreed, a researcher met the patient or family member at the bedside, provided them with a PIS and answered any questions. At least 12 h later, the researcher returned and if the patient or family member consented, an interview time was arranged. 

Interviews and focus groups were conducted in-person, onsite at the two hospitals and lasted 20–60 min. A single female member of the research team (CM) with qualitative research experience conducted the staff and patient interviews, and focus groups were facilitated by this same team member plus a second researcher (male or female) (WT or FL). Researchers kept a memo of reflections and ideas about provisional themes . These researchers were nursing and allied health employees of the health district where the data was collected but were not treating any patient participants and did not work in the same department as any staff participants. Interviews and focus groups were audio-recorded, transcribed verbatim by a professional service, and corrected by the lead researcher (CM). Discussion guides for staff and for patients and family members carers were developed by the research team to target concepts most relevant to the research question (see ). All stakeholder groups were asked similar questions so that the intersection of their perspectives could be considered. The framing of the questions differed between the staff and patient/family discussion guides to ensure relevance to the participant. Discussions began by asking about participants’ experiences of falls and fall prevention in hospital, then sought participants views about implementing evidence-based fall prevention programs. Data collection occurred over 9 months and ceased when preliminary data analysis indicated that sufficient staff and patient perspectives and data quality had been obtained to answer the research question, and interviews/focus groups were not yielding significant new information. 

Transcripts from all stakeholder groups were analysed as a combined dataset using an inductive coding approach guided by Sandelowski’s qualitative description analysis . Inductive analysis was used to develop a coding framework that was applied flexibly to all the transcripts and that continued to evolve in response to further data . NVivo software , spreadsheets, documents and tables were used to assist with data analysis. Two researchers (CM and AH) independently analysed and coded three diverse transcripts (a clinician focus group, patient interview and family member interview) and identified early important concepts and patterns. Through discussion, a preliminary inductive coding framework was developed and was applied flexibly to the first three transcripts and an additional transcript from each stakeholder group. Review of this coding in discussion with multiple members of the research team (CM, AH, CS, WT) was used to further refine the framework and this was applied to all transcripts. Reading within and across this coding generated key themes relevant to the research question. Initial themes were discussed by two members of the research team (CM and AH), refined and then presented to the research team (who had diverse, relevant credentials including PhDs and medical, nursing and allied health degrees) with illustrative quotes for critical review, and refinement. Final themes and subthemes were agreed upon and written up narratively. 

The seven staff focus groups and 15 interviews (all but one with patients and family members) comprised 50 participants including 35 multidisciplinary staff members, 12 patients and three family members of patients from orthopaedic, respiratory, geriatric medicine and general medicine wards. Some staff were in management roles and not associated with a specific ward. Patients were inpatients at the time of interview and family participants were visiting an inpatient. Two of the 12 patients had experienced a fall during their current hospital admission and none of the participating patients had been admitted to hospital due to a fall. No participants dropped out and no repeat interviews occurred. Participant characteristics are summarised in . Three major themes relevant to all stakeholder groups were identified in our inductive analysis, each with subthemes. The themes and subthemes are presented below with brief supporting quotes. Following each theme, we have provided a table with additional examples of data informing the themes. The themes and subthemes are summarised in . Theme 1: Fall prevention is a priority, but whose? Participants across all stakeholder groups indicated they believed patients falling in hospital was a serious problem. They were eager to discuss opportunities to prevent falls and implement fall prevention strategies; however, they tended to focus on other stakeholders’ inaction and seemed reluctant or unable to take responsibility for fall prevention themselves. The two aspects of this theme are expanded on below with brief supporting quotes. More comprehensive illustrative quotes are presented in . 1a. Someone needs to do something. There was an overarching desire to reduce falls and a belief that fall prevention deserved to be a core focus of hospital care, in part because the problem is growing. Patients themselves felt at risk and fearful of falling and both patients and staff reflected on the serious consequences of falls. The prevalence of unavoidable fall including weakness, unsteadiness, pain, medications or prolonged bed rest, as well as the foreign hospital environment, was discussed as was the need for strategies to manage these. “I think everyone's aware of the fact that falls are a really significant risk in the facility and certainly, patients can have really very poor outcomes after a fall.” Nurse, FG5 1b. Whose role is it? Despite the expressed need to address falls in hospitals, when asked to reflect on fall prevention practice and how it may be improved, both staff and patient participants frequently raised the role that others can (and should) play in fall prevention. Staff highlighted the role of other disciplines when discussing both positive and negative fall prevention scenarios. For example, medical and allied health (physiotherapy and occupational therapy) participants frequently raised the pivotal role of nursing staff in fall prevention but also the challenges, and risk to patient falls, when nursing staff are not skilled in mobilising patients. A focus on nursing staff education to address this was raised. Nursing staff however more regularly discussed allied health, particularly physiotherapy and medical responsibilities in hospital fall prevention such as patient education and equipment provision. Nurse 7: “I reckon maybe if fall prevention messaging comes from our physio it would be better, not from us nurses. Nurse 4: “Yeah. Probably from the doctors or the physio.” Nurses 4 & 7, FG4 Staff emphasised the role that patients can, and sometimes should, play in preventing falls in hospitals. However, while patients were often keenly aware of fall risks, and eager for them to be prevented, they seldom felt capable of preventing themselves from falling, or even being able to prioritise thinking about fall prevention, and so looked to hospital staff (mostly nurses) to manage this risk. “The pain was all I could focus on in the early days. I couldn't get my head around anything else for three days. I just couldn't get my head around anything.” Patient 1 Theme 2: Disempowered stakeholders Frustration with feeling disempowered to implement fall prevention strategies was expressed frequently by staff but also by patients and family at times. Four key contributors to this frustration were articulated: competing priorities, complexity of the acute hospital environment, workforce stressors and hierarchical tensions. Theme 2 and these subthemes are presented below with brief supporting quotes. presents them with comprehensive illustrative quotes. 2a. Competing priorities. There were regular insights into the opportunity costs involved in healthcare for hospital patients and a concern that time and resources dedicated to fall prevention may disadvantage other equally (or more) important aspects of care. “It's probably safe to say though that falls aren't always on the top of the agenda. I mean even for a geriatrician, falls are not necessarily always the top of the agenda. There are other factors you're trying to fix and some of those are clinical demands.” Medical Officer 2 Many patients felt unable to prioritise fall prevention, especially early in their hospital stay. This was often due to intense pain, analgesic side effects such as drowsiness, and the general overwhelm associated with a hospital admission. Reflecting the complexity of hospital fall prevention, priorities discussed by patients, such as having their pain managed, were at times the fall risk factors discussed by staff. 2b. Burdened by complexity. Staff of various disciplines, patients and family all reflected on the complexity of the acute hospital setting and systems, and the challenge this poses to implementing effective fall prevention strategies. Factors that contributed to this complexity included the fast-paced, dynamic nature of patient care; variability in ward environments (between wards and shifts); keeping up with increasing and ever-changing policies and procedures; high patient acuity; and the diversity of patient needs and challenges, both between patients and over the course of a patient’s stay. Managing cognitive impairment and language barriers were most frequently raised as patient challenges in fall prevention. “ It's not just the nurse. It's everything else that's going on in the ward at the time… I’m not sure there’s a short cut here, it’s a really challenging issue to address.” Medical Officer 1 2c. Workforce stressors. Workforce stressors, especially for frontline clinical staff, were raised by both staff and patient and family participants as a key challenge for fall prevention implementation. These included staff shortages, inadequate staff-to-patient ratios, high staff turnover, heavy workloads and sub-optimal staff skill mix. Most discussion around workforce stressors concentrated on nursing staff, but at times it extended to clinical staff more broadly, and occasionally to non-clinical staff. “ Nurses have the hardest job in the hospital. There are so many things that could potentially go wrong in their day. They've got so many protocols to follow, and they get hammered when they make a mistake… I don’t know how they do it.” Medical Officer, FG5 2d. Hierarchical tensions. The final issue that appeared to contribute to frustration, and at times helplessness for both staff and patients was the impact of power relations Staff gave examples of interdisciplinary strain where they felt unheard and disrespected by other professions, including being given unrealistic instructions regarding mobilising patients. “The doctors force us to walk patients, put them on the chair, do this and that when they can't. They're literally bed bound, they can’t walk, we can't put them on the toilet.” Nurse 6, FG4 A disconnect between frontline staff and management was evident at times where frontline staff reflected on not feeling heard when raising concerns or potentials solutions relevant to fall prevention, leading to disengagement with the area. Management raised concerns around frontline staff adequately following procedures and protocols. Patients often appeared to sit towards the bottom of the hospital hierarchy, being described by themselves and hospital staff as scared, fearful of falling and highly vulnerable. This vulnerability at times appeared to stem from the workplace complexity and workforce stressors staff were under and patients frequently reflected on their desire to avoid being a ‘nuisance’. “I don’t want to be a nuisance. I’ll just try to do it myself… Oh, well we (patients) all think that way.” Patient 5 Theme 3: Shared responsibility may be a solution All participant groups expressed some positive perspectives about the possibility of successful implementation of fall prevention programs in the acute hospital setting. The concept of shared responsibility—across disciplines and via the meaningful inclusion of patients and families in fall prevention—was most frequently associated with a sense of optimism. Enhanced communication and partnering with patients and families emerged as opportunities achieve shared responsibility. This is discussed in detail in the subthemes below with brief supporting quotes and presented in with comprehensive illustrative quotes. 3a. Connecting across the patient-centred care team. Staff and patients frequently identified occasions where ineffective communication between disciplines and between staff and family members hindered fall prevention efforts. Crucial information about fall risks could be missed in handovers, and staff did not always have time, or the right techniques, for explaining these risks to each patient’s family. Conversely, participants spoke of the positive influence that more meaningful communication between disciplines, frontline and management staff and staff and patients could have on fall prevention. Suggestions included: bedside charts that document patient mobility and care plans, managers listening to frontline staff more effectively to understand their views on fall prevention, and case coordinators who liaise with patients and across staff teams to optimise care quality and safety. “I felt like better communication between everyone or even a case coordinator would have been helpful in making me feel safer.” Patient 7 3b. Partnering with patients and families. Many participants felt that patients could play a more active role in fall prevention. Some focused on patients having greater awareness of fall prevention, while others felt that if patients were to be proactive in reducing their fall risk they need to be empowered to make the right choices about how they mobilise. Participants reflected on the need for fall prevention to feel relevant to all patients, including those who may not feel vulnerable, having not fallen in the past . "It's very hard to imagine what can happen to you, because it's not in your head because you've never gone through it. But if you see somebody similar, and that they've had a weakness or had an accident, and then see how easy it is to fall it might be more important." Patient 12 While participants were largely positive about the role patients could play in fall prevention, many were also conscious of limitations in the capacity of some patients to take on this role due to factors such as cognitive impairment, language barriers and high medical acuity. This parallels with the findings in subtheme 1b where patients did not necessarily feel capable of prioritising fall prevention. In many of the discussions around these challenges, meaningful family involvement was raised as a method of more effectively partnering with patients, both as a means of reminding them about fall risks and of advocating for their safety in hospital. 

Participants across all stakeholder groups indicated they believed patients falling in hospital was a serious problem. They were eager to discuss opportunities to prevent falls and implement fall prevention strategies; however, they tended to focus on other stakeholders’ inaction and seemed reluctant or unable to take responsibility for fall prevention themselves. The two aspects of this theme are expanded on below with brief supporting quotes. More comprehensive illustrative quotes are presented in . 1a. Someone needs to do something. There was an overarching desire to reduce falls and a belief that fall prevention deserved to be a core focus of hospital care, in part because the problem is growing. Patients themselves felt at risk and fearful of falling and both patients and staff reflected on the serious consequences of falls. The prevalence of unavoidable fall including weakness, unsteadiness, pain, medications or prolonged bed rest, as well as the foreign hospital environment, was discussed as was the need for strategies to manage these. “I think everyone's aware of the fact that falls are a really significant risk in the facility and certainly, patients can have really very poor outcomes after a fall.” Nurse, FG5 1b. Whose role is it? Despite the expressed need to address falls in hospitals, when asked to reflect on fall prevention practice and how it may be improved, both staff and patient participants frequently raised the role that others can (and should) play in fall prevention. Staff highlighted the role of other disciplines when discussing both positive and negative fall prevention scenarios. For example, medical and allied health (physiotherapy and occupational therapy) participants frequently raised the pivotal role of nursing staff in fall prevention but also the challenges, and risk to patient falls, when nursing staff are not skilled in mobilising patients. A focus on nursing staff education to address this was raised. Nursing staff however more regularly discussed allied health, particularly physiotherapy and medical responsibilities in hospital fall prevention such as patient education and equipment provision. Nurse 7: “I reckon maybe if fall prevention messaging comes from our physio it would be better, not from us nurses. Nurse 4: “Yeah. Probably from the doctors or the physio.” Nurses 4 & 7, FG4 Staff emphasised the role that patients can, and sometimes should, play in preventing falls in hospitals. However, while patients were often keenly aware of fall risks, and eager for them to be prevented, they seldom felt capable of preventing themselves from falling, or even being able to prioritise thinking about fall prevention, and so looked to hospital staff (mostly nurses) to manage this risk. “The pain was all I could focus on in the early days. I couldn't get my head around anything else for three days. I just couldn't get my head around anything.” Patient 1 

Frustration with feeling disempowered to implement fall prevention strategies was expressed frequently by staff but also by patients and family at times. Four key contributors to this frustration were articulated: competing priorities, complexity of the acute hospital environment, workforce stressors and hierarchical tensions. Theme 2 and these subthemes are presented below with brief supporting quotes. presents them with comprehensive illustrative quotes. 2a. Competing priorities. There were regular insights into the opportunity costs involved in healthcare for hospital patients and a concern that time and resources dedicated to fall prevention may disadvantage other equally (or more) important aspects of care. “It's probably safe to say though that falls aren't always on the top of the agenda. I mean even for a geriatrician, falls are not necessarily always the top of the agenda. There are other factors you're trying to fix and some of those are clinical demands.” Medical Officer 2 Many patients felt unable to prioritise fall prevention, especially early in their hospital stay. This was often due to intense pain, analgesic side effects such as drowsiness, and the general overwhelm associated with a hospital admission. Reflecting the complexity of hospital fall prevention, priorities discussed by patients, such as having their pain managed, were at times the fall risk factors discussed by staff. 2b. Burdened by complexity. Staff of various disciplines, patients and family all reflected on the complexity of the acute hospital setting and systems, and the challenge this poses to implementing effective fall prevention strategies. Factors that contributed to this complexity included the fast-paced, dynamic nature of patient care; variability in ward environments (between wards and shifts); keeping up with increasing and ever-changing policies and procedures; high patient acuity; and the diversity of patient needs and challenges, both between patients and over the course of a patient’s stay. Managing cognitive impairment and language barriers were most frequently raised as patient challenges in fall prevention. “ It's not just the nurse. It's everything else that's going on in the ward at the time… I’m not sure there’s a short cut here, it’s a really challenging issue to address.” Medical Officer 1 2c. Workforce stressors. Workforce stressors, especially for frontline clinical staff, were raised by both staff and patient and family participants as a key challenge for fall prevention implementation. These included staff shortages, inadequate staff-to-patient ratios, high staff turnover, heavy workloads and sub-optimal staff skill mix. Most discussion around workforce stressors concentrated on nursing staff, but at times it extended to clinical staff more broadly, and occasionally to non-clinical staff. “ Nurses have the hardest job in the hospital. There are so many things that could potentially go wrong in their day. They've got so many protocols to follow, and they get hammered when they make a mistake… I don’t know how they do it.” Medical Officer, FG5 2d. Hierarchical tensions. The final issue that appeared to contribute to frustration, and at times helplessness for both staff and patients was the impact of power relations Staff gave examples of interdisciplinary strain where they felt unheard and disrespected by other professions, including being given unrealistic instructions regarding mobilising patients. “The doctors force us to walk patients, put them on the chair, do this and that when they can't. They're literally bed bound, they can’t walk, we can't put them on the toilet.” Nurse 6, FG4 A disconnect between frontline staff and management was evident at times where frontline staff reflected on not feeling heard when raising concerns or potentials solutions relevant to fall prevention, leading to disengagement with the area. Management raised concerns around frontline staff adequately following procedures and protocols. Patients often appeared to sit towards the bottom of the hospital hierarchy, being described by themselves and hospital staff as scared, fearful of falling and highly vulnerable. This vulnerability at times appeared to stem from the workplace complexity and workforce stressors staff were under and patients frequently reflected on their desire to avoid being a ‘nuisance’. “I don’t want to be a nuisance. I’ll just try to do it myself… Oh, well we (patients) all think that way.” Patient 5 

All participant groups expressed some positive perspectives about the possibility of successful implementation of fall prevention programs in the acute hospital setting. The concept of shared responsibility—across disciplines and via the meaningful inclusion of patients and families in fall prevention—was most frequently associated with a sense of optimism. Enhanced communication and partnering with patients and families emerged as opportunities achieve shared responsibility. This is discussed in detail in the subthemes below with brief supporting quotes and presented in with comprehensive illustrative quotes. 3a. Connecting across the patient-centred care team. Staff and patients frequently identified occasions where ineffective communication between disciplines and between staff and family members hindered fall prevention efforts. Crucial information about fall risks could be missed in handovers, and staff did not always have time, or the right techniques, for explaining these risks to each patient’s family. Conversely, participants spoke of the positive influence that more meaningful communication between disciplines, frontline and management staff and staff and patients could have on fall prevention. Suggestions included: bedside charts that document patient mobility and care plans, managers listening to frontline staff more effectively to understand their views on fall prevention, and case coordinators who liaise with patients and across staff teams to optimise care quality and safety. “I felt like better communication between everyone or even a case coordinator would have been helpful in making me feel safer.” Patient 7 3b. Partnering with patients and families. Many participants felt that patients could play a more active role in fall prevention. Some focused on patients having greater awareness of fall prevention, while others felt that if patients were to be proactive in reducing their fall risk they need to be empowered to make the right choices about how they mobilise. Participants reflected on the need for fall prevention to feel relevant to all patients, including those who may not feel vulnerable, having not fallen in the past . "It's very hard to imagine what can happen to you, because it's not in your head because you've never gone through it. But if you see somebody similar, and that they've had a weakness or had an accident, and then see how easy it is to fall it might be more important." Patient 12 While participants were largely positive about the role patients could play in fall prevention, many were also conscious of limitations in the capacity of some patients to take on this role due to factors such as cognitive impairment, language barriers and high medical acuity. This parallels with the findings in subtheme 1b where patients did not necessarily feel capable of prioritising fall prevention. In many of the discussions around these challenges, meaningful family involvement was raised as a method of more effectively partnering with patients, both as a means of reminding them about fall risks and of advocating for their safety in hospital. 

Our qualitative study with multiple key stakeholder groups in fall prevention identified three main issues that are important to consider when implementing fall prevention programs in the acute hospital setting. Stakeholders believed fall prevention to be an important issue but one best prioritised by others, while staff and patients felt frustrated and disempowered implementing fall prevention due primarily to complexity of the setting and workforce challenges. However, participants agreed that shared responsibility provided an opportunity to support the implementation of fall prevention programs more effectively. Our finding that stakeholders believed hospital fall prevention to be a priority contrasts with insights on fall prevention provided in other qualitative studies. For example, Meyer et al. found ‘falls are not a priority- for the older person or treating hospital health professionals’ . While some of our participants admitted finding it difficult to prioritise fall prevention there appeared a genuine desire to overcome this. Many patients in our study also reflected on being keenly aware of, and often worried about, their risk of falling while in hospital. This differs from studies which found that many inpatients were unaware of their risk of falling while hospital , suggesting widespread variability in patient perception of fall risks. While most of our patient participants were concerned about their risk of falling, they appeared at times disempowered to engage in effective fall prevention behaviour. Similar findings have emerged in other recent hospital fall prevention studies, such as Hill’s 2023 qualitative study with older hospital consumers . While the importance of patient centred care is well established , studies such as ours suggest that issues with patient communication and confidence may be hindering true patient clinician partnerships. Ensuring personalised and tailored individual approaches to fall prevention, as recommended under hospital prevention in the World Falls Guidelines, may bolster success at genuine patient engagement . The workplace frustration and workforce disempowerment that participants reported around implementing hospital fall prevention programs is supported by the findings of other studies exploring the implementation of safety and quality programs in hospitals . In these studies, healthcare professionals reveal organisational silos, inappropriate workforce skill mix and challenges working effectively in multidisciplinary teams as barriers to implementing programs to improve care of older people (including via fall prevention) in hospital . A recent systematic review highlighted the global challenge of hospital nursing workforce shortages and the complex influences on and effects of this such as staff turnover, stress and burnout . The desire for shared responsibility for the implementation of fall prevention programs discussed by study participants supports the calls for greater shared ownership of care across many facets of patient safety . We found that ineffective communication between disciplines, frontline and management staff and staff and patients, at times, impedes shared responsibility. The challenge of executing this critical component of high quality, safe patient care has been highlighted in other studies specific to falls  and more broadly in work investigating patient harm in hospital  suggesting the need for specific focus on achieving implementation of effective communication in this space. Staff, patients’ and patient families’ desire to partner to address falls is also supported by other studies investigating engagement in fall prevention . However, diverse patient characteristics, patients and family feeling overwhelmed in the acute hospital setting and varied expectations of the level of patient and family involvement, suggest the need for individual tailoring of this involvement , a focus of the hospital fall prevention section of the World Falls Guidelines . Strengths and limitations The strengths of this study include the diverse range and significant number of stakeholders that participated in interviews and focus groups. Ongoing analysis indicated that the sample size and diversity was adequate to answer our research questions as towards the end of recruitment interviews and focus groups were not yielding significantly new conceptual information . Strategies were used to enable participants to speak freely and provide rich insights . These included the use of experienced moderators who were able to build trust with participants through their relevant clinical experience and independence from management or treating roles with participants, and the privacy of interviews for patients and family members Data analysis followed an inductive, descriptive approach to allow deep exploration of the data while remaining open to the full range of considerations that may shape how fall prevention strategies are implemented (or not) in these settings . This approach was chosen over the use of an a-priori theoretical framework as it enabled the data-driven development of a conceptual framework in the context of an unexplored implementation gap . Participants were invited from wards that hospital management identified as having high patient fall rates, as it was thought they would be likely to have high fall risk patients and an interest in hospital fall prevention. While this provided valuable insights into challenges and opportunities in implementing effective hospital fall prevention practices, it may not have captured learnings from wards that may be successfully implementing effective fall prevention strategies, contributing to very low fall rates. Participants also self-selected to take part in the study that means our participants may have been more engaged, interested, familiar and motivated about fall prevention that non-participants. There are additional limitations to our study. The research was conducted across two acute public hospitals in one state of Australia. While the two hospitals provide contrast in terms of size and the diversity of cultural backgrounds of patient and staff, they are both located in a large city that limits the transferability to other hospital settings such as those in rural or regional areas, or other states and countries. While participants who could not speak English were invited to participate in an interview with an interpreter, we did not manage to recruit anyone with this characteristic. We did however have six staff and three patient participants for whom English was not their first language. Implications This study has highlighted an array of challenges in the implementation of hospital fall prevention programs and has suggested shared responsibility for fall prevention as a potential component for implementation success. However, the question of how to effectively improve interdisciplinary communication and partner with patients and families to increase stakeholders’ sense of shared responsibility for implementing fall prevention strategies alongside these challenges remains. The use of implementation frameworks may be one mechanism to assist with bridging the gap to practical steps to implementing fall prevention programs. For example, when we consider our findings against the Five Cs (comprehension, compassion, collaboration, coordination, convergence) framework for safety culture change in healthcare , key implications emerge. ‘Comprehension’ of the problem is evident with stakeholders wanting fall prevention to be prioritised. However, their commitment to prioritising fall prevention themselves emerges as a barrier in the ‘compassion’ component of the framework which focuses on how values are manifested in practice, suggesting this area needs attention. ‘Collaboration’ poses a promising strategy to support the implementation of fall prevention programs, harnessing the desire for shared responsibility highlighted in our study. To extend the collaboration to ensure ‘coordination’ of fall prevention programs would, however, require attention to system processes and infrastructure as they appear to contribute to the burden staff and patients expressed. Finally, ‘convergence’ of effective leadership across all levels of an organization emerges as an absent undercurrent across our findings and one that if explicitly addressed may help harness improvements in fall prevention practice. Effective leadership in healthcare fosters a balance of empowerment and accountability and emphasises teamwork ; an approach supported by the findings of this study. Mapping findings such as these to implementation frameworks will be strengthened by the addition of local data, supporting a balance of implementing research findings alongside frontline knowledge of local requirements and challenges . The results of application of such frameworks to fall prevention implementation warrants the focus of future research. The intersection of diverse stakeholder involvement in fall prevention implementation highlighted in our study suggests the importance of meaningful stakeholder consultation and patient and staff empowerment when utilising frameworks to design and evaluate fall prevention implementation strategies. 

The strengths of this study include the diverse range and significant number of stakeholders that participated in interviews and focus groups. Ongoing analysis indicated that the sample size and diversity was adequate to answer our research questions as towards the end of recruitment interviews and focus groups were not yielding significantly new conceptual information . Strategies were used to enable participants to speak freely and provide rich insights . These included the use of experienced moderators who were able to build trust with participants through their relevant clinical experience and independence from management or treating roles with participants, and the privacy of interviews for patients and family members Data analysis followed an inductive, descriptive approach to allow deep exploration of the data while remaining open to the full range of considerations that may shape how fall prevention strategies are implemented (or not) in these settings . This approach was chosen over the use of an a-priori theoretical framework as it enabled the data-driven development of a conceptual framework in the context of an unexplored implementation gap . Participants were invited from wards that hospital management identified as having high patient fall rates, as it was thought they would be likely to have high fall risk patients and an interest in hospital fall prevention. While this provided valuable insights into challenges and opportunities in implementing effective hospital fall prevention practices, it may not have captured learnings from wards that may be successfully implementing effective fall prevention strategies, contributing to very low fall rates. Participants also self-selected to take part in the study that means our participants may have been more engaged, interested, familiar and motivated about fall prevention that non-participants. There are additional limitations to our study. The research was conducted across two acute public hospitals in one state of Australia. While the two hospitals provide contrast in terms of size and the diversity of cultural backgrounds of patient and staff, they are both located in a large city that limits the transferability to other hospital settings such as those in rural or regional areas, or other states and countries. While participants who could not speak English were invited to participate in an interview with an interpreter, we did not manage to recruit anyone with this characteristic. We did however have six staff and three patient participants for whom English was not their first language. 

This study has highlighted an array of challenges in the implementation of hospital fall prevention programs and has suggested shared responsibility for fall prevention as a potential component for implementation success. However, the question of how to effectively improve interdisciplinary communication and partner with patients and families to increase stakeholders’ sense of shared responsibility for implementing fall prevention strategies alongside these challenges remains. The use of implementation frameworks may be one mechanism to assist with bridging the gap to practical steps to implementing fall prevention programs. For example, when we consider our findings against the Five Cs (comprehension, compassion, collaboration, coordination, convergence) framework for safety culture change in healthcare , key implications emerge. ‘Comprehension’ of the problem is evident with stakeholders wanting fall prevention to be prioritised. However, their commitment to prioritising fall prevention themselves emerges as a barrier in the ‘compassion’ component of the framework which focuses on how values are manifested in practice, suggesting this area needs attention. ‘Collaboration’ poses a promising strategy to support the implementation of fall prevention programs, harnessing the desire for shared responsibility highlighted in our study. To extend the collaboration to ensure ‘coordination’ of fall prevention programs would, however, require attention to system processes and infrastructure as they appear to contribute to the burden staff and patients expressed. Finally, ‘convergence’ of effective leadership across all levels of an organization emerges as an absent undercurrent across our findings and one that if explicitly addressed may help harness improvements in fall prevention practice. Effective leadership in healthcare fosters a balance of empowerment and accountability and emphasises teamwork ; an approach supported by the findings of this study. Mapping findings such as these to implementation frameworks will be strengthened by the addition of local data, supporting a balance of implementing research findings alongside frontline knowledge of local requirements and challenges . The results of application of such frameworks to fall prevention implementation warrants the focus of future research. The intersection of diverse stakeholder involvement in fall prevention implementation highlighted in our study suggests the importance of meaningful stakeholder consultation and patient and staff empowerment when utilising frameworks to design and evaluate fall prevention implementation strategies. 

Multidisciplinary staff across organisation levels, and patients and their families, provided genuine and representative insights to consider in the implementation of hospital fall prevention programs in the acute hospital setting. Hospital fall prevention is viewed as a priority by these stakeholder groups, but challenges related to role perception, competing priorities, workforce pressure and disempowerment mean that, in practice, fall prevention is often neglected. Increasing shared responsibility for fall prevention across disciplines and organisational levels, and between patients, family and staff may help overcome this. Future research should focus on the design and evaluation of implementation strategies to address the highlighted challenges and implement methods for fostering genuine shared responsibility for fall prevention in practice. 

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