Table 4.

Interventions in implementation strategy

Barriers	Strategy	Targeted Interventions
Lack of supporting staff	Change champions	An implementation team, comprising the Deputy Director of Nursing, seven Nursing Unit Managers, four senior nursing staff and a geriatric physician, oversaw the project in terms of planning and implementing the interventions with the research team.
		Senior nursing staff were engaged as change champions to reinforce and encourage nurses to adhere to the strategies recommended in the guidelines.
		A 'fall nurse specialist' was employed to prescribe interventions according to risk factors identified; monitor compliance of nurses with the interventions; educate high-risk patients, their families and carers on fall prevention interventions; and conduct post-fall assessments and evaluations.
Lack of knowledge and education	Educational sessions	Educational sessions were aimed at promoting and supporting the adoption of the recommendations in the fall prevention guidelines. These interactive workshops included discussion of the importance of fall prevention, the role of fall risk assessment and identification of fall risk factors, skills required to do a fall risk assessment, and interventions for preventing falls. Nurses were also given a pre- and post-education knowledge test to assess their learning following these sessions.
Lack of resources	Reminders & Identification systems	Reminder methods included the mandatory fall risk assessment tool incorporated in nursing assessment notes, prompting nurses to perform fall risk assessment upon admission and at every change of shift. All nurses were also given a pocket card which detailed the summary of the recommendations in the CPG. Posters on the Fall Prevention CPG were posted in all the participating wards to remind health care providers to use the guidelines.
		Identification systems were used to alert staff to patients assessed as at risk of a fall. These systems included: 1) pink name cards above the bed; 2) pink stickers on clinical/nursing notes; and 3) pink identification bracelets on the high risk patient.
Lack of facilities	Improved facilities	Improved facilities such as night lights, bed alarm devices, and facilities to maintain the equipment, were available in all the participating wards.
Lack of motivation	Audit and feedback	Audit and feedback strategies were employed with aggregate audit data on incidence of falls and compliance to use of the fall risk assessment tool, being posted in the department tea room at monthly intervals. The data were presented as simple tables and text, with feedback highlighting good practice, areas requiring improvement, and suggestions on how to achieve the change. Incentives such as McDonalds' vouchers were given monthly to the staff of the ward with the lowest fall rate and highest compliance to fall risk assessment.