A realist evaluation of a multifactorial falls prevention programme in care homes

Background falls in care homes are common, costly and hard to prevent. Multifactorial falls programmes demonstrate clinical and cost-effectiveness, but the heterogeneity of the care home sector is a barrier to their implementation. A fuller appreciation of the relationship between care home context and falls programme delivery will guide development and support implementation. Methods this is a multi-method process evaluation informed by a realist approach. Data include fidelity observations, stakeholder interviews, focus groups, documentary review and falls-rate data. Thematic analysis of qualitative data and descriptive statistics are synthesised to generate care home case studies. Results data were collected in six care homes where a falls programme was trialled. Forty-four interviews and 11 focus groups complemented observations and document review. The impact of the programme varied. Five factors were identified: (i) prior practice and (ii) training may inhibit new ways of working; (iii) some staff may be reluctant to take responsibility for falls; (iv) some may feel that residents living with dementia cannot be prevented from falling; and, (v) changes to management may disturb local innovation. In some care homes, training and improved awareness generated a reduction in falls without formal assessments being carried out. Conclusions different aspects of the falls programme sparked different mechanisms in different settings, with differing impact upon falls. The evaluation has shown that elements of a multifactorial falls programme can work independently of each other and that it is the local context (and local challenges faced), which should shape how a falls programme is implemented.