Aim To develop an implementation plan for delirium prevention. Background The use of non‐pharmacological interventions to prevent hospital‐acquired delirium is well established but their implementation has been notoriously difficult to achieve. Systematic analysis of context as part of implementation planning is critical. Methods Ethnographic study was conducted in a 24‐bed general medical ward. Eleven patients and family members and 15 health service staff participated through observations, individual interviews and document review. Inductive analysis was used to generate themes that described enablers and barriers. Results Enablers included a ward culture that embraced safety and placing the person at the centre of care. Barriers were in tension with the enablers and included limited staff knowledge, specialist forms exclusive to the nursing discipline, inflexible ward routines and frequent disruptions. Conclusions In addition to standard implementation strategies such as individual education and leadership, implementing delirium prevention requires consideration of team practices, review of policy document design and identification of outcomes data than can support collaborative reflexive practice. Implications for Nursing Management The use of a theory‐informed ethnographic approach exposed tensions that may be otherwise invisible. Understanding the tensions increases the likelihood of implementation success. Using a systematic assessment approach can create a comprehensive implementation plan.

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.

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In the clinical setting, simulation is emerging as an important educational technology for learning about contemporary clinical care. The aim of this case study was to illustrate the feasibility of simulation as a research translation mechanism. Designing and delivering a simulated learning activity for delirium prevention was a key implementation strategy in a larger study focused on translating research evidence into practice. Using evidence about delirium prevention, and in collaboration with key stakeholders, the simulation team developed a delirium prevention scenario that was conducted four times with nurses in the participating ward. This study suggests that the use of simulation design and delivery as a research translation mechanism is feasible. Based on this experience, further research into how simulations can function as research translation mechanisms is recommended, with a view to improve patient outcomes through supported practice change.

Background While advances in falls prevention in the adult population have occurred, the care requirements for older patients with cognitive impairment at risk of falling are less established. Objectives To identify interventions to prevent in‐hospital falls in older patients with cognitive impairment for further research and describe the strategies used to implement those interventions. Design A seven‐stage mixed studies review was used. Methods Seven electronic databases were searched. The SPIDER framework guided the review question and selection of search terms. The Mixed Methods Assessment Tool was used to appraise the quality of research studies, and the Quality Improvement Minimum Quality Data Set was used to appraise the quality of quality improvement projects. A convergent qualitative synthesis was used to analyse the extracted data. The adapted PRISMA guideline informed the procedures. Results Ten projects (five quality improvements and five researches) were included. Five themes emerged from the synthesis: engaging with families in falls prevention, assessing falls risk to identify interventions, extending nursing observation through technology, conducting a medication review and initiating nonpharmacological delirium prevention interventions. Implementation was not well described and commonly focused on capital investment to initiate a falls prevention programme and education to introduce staff to the new techniques for practice. Conclusions Emerging research and quality improvement studies demonstrate that effective falls prevention with this vulnerable population is possible but requires further investigation before widespread practice recommendations can be made. Further research and quality improvement in this area should consider adoption of an implementation framework to address sustainability. Relevance to clinical practice Reducing falls in older people with cognitive impairment requires nurses to work more closely with pharmacists, occupational therapists and social workers to develop strategies that work and are sustainable.