Aims and objectives:To explore nurse and nursing assistant reflections on the care of older patients with cognitive impairment who have experienced a fall.Background: While there are evidence-based clinical guidelines for the prevention and management of falls and for the care of older people with cognitive impairment, the falls rates for older people with cognitive impairment are three times as high as those without. Design: Critical incident technique.Methods: Eleven registered and two enrolled nurses and four assistants in nursing working in one subacute and two acute wards within two hospitals of a tertiary level health service in south-east Queensland. Individual semistructured interviews focused on two past events when a patient with cognitive impairment had fallen in hospital: one when there was minimal harm and the second when there was significant harm. Thematic analysis was undertaken. The COREQ checklist was followed.Results: Three themes emerged from 23 reflective accounts of fall events: "direct observation is confounded by multiple observers" and "knowing the person has cognitive impairment is not enough," and "want to rely on the guideline but unsure how to enact it." While participants were aware of the falls prevention policy and techniques available to prevent falls, the implementation of these was challenging due to the complexity of care required by the older person with cognitive impairment. Conclusions:Falls prevention for older people with cognitive impairment is complex and belies the simple application of policy. Relevance to clinical practice:To reduce falls, nurses can involve the family to support "knowing the patient" to enable prediction of impulsive actions; shift the focus of in-service from lectures to specific case presentations, with collaborative analysis on personfocused strategies to prevent falls in older people with cognitive impairment; and reconsider the sitter role from simple observer to assistant, focused on ambulation and supporting independence in activities of daily living. K E Y W O R D Sdementia, falls, hospitalised patients, older patients, patient safety | 1347 GREALISH Et AL.

Background: Evidence-based guidelines assist clinicians in practice, but how the guidelines are implemented is less established.Aim: To describe the nurses' implementation of activities recommended in evidence-based guidelines for falls prevention and care of older people with cognitive impairment.Methods: Structured observation with a categorical checklist was used. Nursing personnel were recruited from one subacute and two acute wards in two hospitals in one tertiary-level health service in south-eastern Queensland, Australia. The data collection instrument identified 31 activities drawn directly from the evidence-based guidelines, which were categorized into six domains of nursing practice: clinical care, comfort, elimination, mobility, nutrition and hydration, and social engagement. Four-hour observation periods, timed to occur across the morning and evening shifts, were conducted over 2 months.Results: Nineteen registered nurses, six enrolled nurses, and 16 assistants in nursing (N = 41) were observed for 155 hr of observation. There was variability in adherence with specific activities, ranging from 21% to 100% adherence. Three categories with the highest adherence were nutrition and hydration, mobilization safety, and social engagement. The clinical care, comfort, and elimination categories had lower adherence, with lowest adherence in activities of education provision about falls risk, pain assessment, using a clock or calendar to reorient to time and place, and bowel care.Linking Evidence to Action: Nursing care is delivered within an interdisciplinary team. Therefore, responsibility for the everyday fundamental care activities known to prevent falls in older people with cognitive impairment requires localized negotiation. A practical guide for preventing in-hospital falls in older people with cognitive impairment addressing the interdisciplinary context of practice is required. Interdisciplinary teams should develop strategies to enhance the implementation of pain assessment and prevention of constipation in the context of regularly implemented hydration, nutrition, and mobilization care strategies.