Exploring the influence of hospital context on acute care physical therapy fall prevention practice: A qualitative study.

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Published in final edited form as: Physiother Theory Pract. 2025 Jan 7;41(8):1675–1693. doi: 10.1080/09593985.2024.2447923 Search in PMC Search in PubMed View in NLM Catalog Add to search Exploring the influence of hospital context on acute care physical therapy fall prevention practice: A qualitative study James P Crick Jr James P Crick Jr , DPT, PhD a University Hospitals, The Ohio State University Wexner Medical Center, Columbus, OH, USA b School of Health and Rehabilitation Sciences, The Ohio State University, Columbus, OH, USA c CATALYST, The Center for the Advancement of Team Science, Analytics, and Systems Thinking in Health Services and Implementation Science Research, The Ohio State University, Columbus, OH, USA Find articles by James P Crick Jr a, b, c , Gideon Hewitt Gideon Hewitt , BS, SPT b School of Health and Rehabilitation Sciences, The Ohio State University, Columbus, OH, USA Find articles by Gideon Hewitt b , Lisa Juckett Lisa Juckett , OTR/L, CHT, PhD b School of Health and Rehabilitation Sciences, The Ohio State University, Columbus, OH, USA d Division of Occupational Therapy, School of Health and Rehabilitation Sciences, The Ohio State University, Columbus, OH, USA Find articles by Lisa Juckett b, d , Marka Salsberry Marka Salsberry , DPT b School of Health and Rehabilitation Sciences, The Ohio State University, Columbus, OH, USA e Division of Trauma, Department of Orthopaedics, The Ohio State University College of Medicine, Columbus, OH, USA Find articles by Marka Salsberry b, e , Carmen E Quatman Carmen E Quatman , MD, PhD b School of Health and Rehabilitation Sciences, The Ohio State University, Columbus, OH, USA e Division of Trauma, Department of Orthopaedics, The Ohio State University College of Medicine, Columbus, OH, USA Find articles by Carmen E Quatman b, e , Catherine C Quatman-Yates Catherine C Quatman-Yates , DPT, PhD b School of Health and Rehabilitation Sciences, The Ohio State University, Columbus, OH, USA f Division of Physical Therapy, School of Health and Rehabilitation Sciences, The Ohio State University, Columbus, OH, USA Find articles by Catherine C Quatman-Yates b, f Author information Article notes Copyright and License information a University Hospitals, The Ohio State University Wexner Medical Center, Columbus, OH, USA b School of Health and Rehabilitation Sciences, The Ohio State University, Columbus, OH, USA c CATALYST, The Center for the Advancement of Team Science, Analytics, and Systems Thinking in Health Services and Implementation Science Research, The Ohio State University, Columbus, OH, USA d Division of Occupational Therapy, School of Health and Rehabilitation Sciences, The Ohio State University, Columbus, OH, USA e Division of Trauma, Department of Orthopaedics, The Ohio State University College of Medicine, Columbus, OH, USA f Division of Physical Therapy, School of Health and Rehabilitation Sciences, The Ohio State University, Columbus, OH, USA ✉ CONTACT James P. Crick Jr. DPT, PhD, [email protected] , University Hospitals, The Ohio State University Wexner Medical Center, 539 Doan Hall, 410 West 10th Avenue, Columbus, OH 43210, USA Issue date 2025 Aug. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed, or built upon in any way. The terms on which this article has been published allow the posting of the Accepted Manuscript in a repository by the author(s) or with their consent. Full Terms & Conditions of access and use can be found at https://www.tandfonline.com/action/journalInformation?journalCode=iptp20 PMC Copyright notice PMCID: PMC13081786  NIHMSID: NIHMS2159417  PMID: 39773398 The publisher's version of this article is available at Physiother Theory Pract Abstract Background: Falls are a significant concern for hospitals and patients. The risk of falls is particularly heightened around the period of hospitalization. Physical therapy (PT) is commonly consulted for hospitalized patients at-risk for falls, yet it is unknown how the hospital context influences fall prevention practice among physical therapists. Purpose: To explore the perspectives of acute care physical therapists on fall prevention practices within hospital settings and examine how specific contextual factors influence their practice patterns and the effectiveness of PT interventions. Methods: A prospective qualitative study using collaborative qualitative data analysis was conducted through semi-structured interviews with acute care physical therapists nationwide. Interviews focused on therapists’ perceptions of fall prevention practices, PT intervention effectiveness, and the influence of hospital context. Results: We derived three primary themes and ten subthemes. First, mobility promotion was identified as central to fall prevention, requiring a system-wide culture involving multidisciplinary teams, particularly nursing staff. Second, systemic factors, such as time constraints, institutional priorities, high patient volumes, staff availability, equipment availability, and the physical environment, were found to limit optimal PT practice for fall prevention. Third, the effectiveness of PT interventions was context-dependent, with therapists adapting their practices to maximize impact within systemic constraints. Notably, clinical experience seemed to mitigate some practice limitations. Conclusions: Despite the acknowledged benefits of PT, systemic factors often prevent therapists from implementing effective fall prevention interventions. Addressing these contextual barriers and developing standards of practice may enhance patient safety and the overall success of fall prevention efforts in hospitals. Keywords: Fall prevention, physical therapy, hospital, acute care, contextual factors Introduction Patient falls are a significant concern within healthcare settings, both during and following hospitalization. About one in four community-dwelling older adults in the United States (US) experience a fall each year ( CDC, 2019 ). Annually these falls contribute to approximately one million hospital admissions and between two to three million emergency department visits ( CDC, 2019 ; Reider et al., 2024 ). The annual expense of managing falls in US hospitals is estimated at $19.8 billion ( Reider et al., 2024 ). Studies among older adults indicate that the risk for falls with injury nearly doubles one month prior to admission and nearly quadruples within one week of hospital admission ( Hoffman et al., 2020 ). Post-discharge, older adults face significantly increased fall rates, particularly during the first three weeks ( Qian et al., 2023 ), ( Qian et al., 2023 ). In-hospital fall incidence varies across different hospital unit types, ranging from 5.7 falls per 1,000 bed days in general units ( Shorr et al., 2012 ) to as high as 18 falls per 1,000 patient bed days in a specialized elderly care ward ( Healey et al., 2004 ), highlighting the varying risk environments within hospital settings. An estimated 30–50% of in-hospital falls result in injuries ( Brandis, 1999 ; Schwendimann, Bühler, de Geest, and Milisen, 2008 ), with consequences including elevated health care costs and increased likelihood of requiring post-acute rehabilitative care ( Aditya, Sharma, Allen, and Vassallo, 2003 ; Bates, Pruess, Souney, and Platt, 1995 ). Efforts to reduce in-hospital falls intensified after the Centers for Medicare and Medicaid Services (CMS) classified falls with injuries as “never events” in 2008 ( Lembitz and Clarke, 2009 ; Michaels et al., 2007 ), eliminating reimbursement for treating such injuries ( Center for Medicare & Medicaid Services, 2008 ; Golladay, Collins, Ashcraft, and Dorrill, 2010 ; Jarrett and Callaham, 2016 ; Lembitz and Clarke, 2009 ). ( Center for Medicare & Medicaid Services, 2008 ; Golladay, Collins, Ashcraft, and Dorrill, 2010 ; Jarrett and Callaham, 2016 ; Lembitz and Clarke, 2009 ). It has been persuasively argued that fall prevention efforts have resulted in an epidemic of immobility among hospitalized patients ( Brown, 2020 ; Brown, Friedkin, and Inouye, 2004 ; Brown, Redden, Flood, and Allman, 2009 ; Greysen, 2016 ; Zisberg et al., 2011 ), contributing to negative patient outcomes ( Fisher et al., 2016 ; Growdon, Shorr, and Inouye, 2017 ; Loyd et al., 2020 ; Pavon et al., 2020 ; Shadmi and Zisberg, 2011 ; Zisberg et al., 2011 ). In hospital settings, physical therapy (PT) plays an important role, particularly for patients at risk of falling or those with mobility limitations. Clinical decision-making in this context is complex and influenced by factors such as the patient’s medical background, the therapist’s knowledge and experience, and the specifics of the hospital environment ( Holdar, Wallin, and Heiwe, 2013 ; Jette, Grover, and Keck, 2003 ; Masley et al., 2011 ). There is growing evidence that increased frequency of PT interventions leads to better patient outcomes, such as enhanced functional improvement ( Hartley et al., 2016 ; Johnson et al., 2022 ; Peiris et al., 2018 ) and increased chances of being discharged to home ( Freburger, 1999 , 2000 ; Johnson, Lapin, Green, and Stilphen, 2021 , 2022 ). In addition, following the discharge recommendations provided by acute care physical therapists has been consistently linked with reduced hospital readmission rates ( Chou et al., 2021 ; Shoemaker et al., 2019 ; Smith, Fields, and Fernandez, 2010 ; Wright et al., 2023 ). This is key as 10–17% of all readmissions are associated with post-hospital falls ( Galet, Zhou, Eyck, and Romanowski, 2018 ; Hoffman et al., 2019 ). Despite the acknowledged benefits of PT in these settings, there is a notable knowledge gap regarding how the context of the hospital environment influences PT practices related to fall prevention. To bridge this gap, it is essential to consider the contextual factors that might influence such practices. Contextual factors, as we defined for participants, include “any elements associated with the hospital setting that influence your daily practice.” Examples may include culture, communication structures, and/or availability of resources ( Table 1 ). This definition aligns with the inner setting domain constructs of our guiding meta-theoretical framework, the Consolidated Framework for Implementation Research (CFIR) ( Damschroder et al., 2009 ). Addressing this research gap is necessary to understand the contextual influences on PT practices for fall prevention, allowing for creation of standards of practice to enhance patient safety and the overall success of fall prevention in hospital settings. Table 1. Definitions for inner setting domain of the consolidated framework for implementation research (CFIR) x and for model components of the multi-systemic Fall prevention Model. y Construct Definition Culture x Norms, values, and basic assumptions of a given organization. Structural characteristics x The social architecture, age, maturity, and size of an organization. Networks and communications x The nature and quality of webs of social networks and the nature and quality of formal and informal communications within an organization. Implementation climate x The absorptive capacity for change, shared receptivity of involved individuals to an intervention, and the extent to which use of that intervention will be rewarded, supported, and expected within their organization. Environment y Describes the built environment of the hospital including room setup, flooring, lighting, equipment, and furniture. Care processes and culture y Focuses on the procedures, routines, and cultural aspects of hospital-based care. Technology y Describes solutions requiring technological investment including audible alarm systems, electronic medical records, accelerometers, video sitters, etc. Open in a new tab The purpose of this study is to explore and understand the perspectives of acute care physical therapists on fall prevention practices within hospital settings, examining how specific contextual factors influence their practice patterns and the effectiveness of PT interventions. This study follows a national survey of acute care physical therapists regarding their perceptions of fall prevention practice, the effectiveness of PT to contribute to reduced falls risk, and if hospital context influences practice ( Crick et al., 2023 ). The survey revealed therapists broadly agree on the effectiveness of acute PT for fall-prevention, yet less experienced therapists acknowledged the hospital context more significantly limits their practice as compared to experienced therapists (odds ratio 3.90, p < .001). This contrast between novice and seasoned therapists was a novel finding necessitating further investigation, as was how and what contextual factors are most limiting to physical therapist practice. The collective goal of these studies is to enhance patient safety and outcomes by developing a more comprehensive and effective fall prevention approach, including maximizing the impact of PT care. This work is thus a vital foundation for formulating tailored interventions to develop a fall prevention standard of care for acute care physical therapists. Methods Research paradigm and methodological approach This study is grounded in a constructivist ontology and interpretivist epistemology, acknowledging that reality is socially constructed and varies according to individual experiences ( Ponterotto, 2005 ). From a constructivist perspective, we recognize that multiple realities exist, shaped by the unique clinical encounters and perceptions of physical therapists in acute care settings. Our interpretivist epistemology aligns with the belief that knowledge is co-constructed between researchers and participants, where understanding of the phenomenon emerges through the subjective interpretations shared during the research process ( Klem, Shields, Smith, and Bunzli, 2022 ; Lincoln, Lynham, and Guba, 2011 ). Thus, this study sought to explore how physical therapists perceive fall prevention within acute care practice and how contextual factors influence their practices and interactions with patients. Axiologically, we respect the values and ethical commitments of both researchers and participants, recognizing that each brings their own perspectives on the importance and challenges of fall prevention ( Ponterotto, 2005 ). These values informed the design, data collection, and iterative interpretation processes, including a reflexive approach that prioritized participant experiences and ethical considerations in acute care practice. Methodologically, we employed a collaborative qualitative data analysis using a constant comparison method ( Richards and Hemphill, 2018 ). This approach allowed us to iteratively compare and contrast data across cases, capturing both unique and shared interpretations of fall prevention practices among clinician participants. We sought to report findings consistent with an interpretive description to emphasize both the nuanced, contextually grounded insights of individual therapists and the practical implications of our findings for clinical practice ( Thorne, 2016 ). This study was approved by our Institutional Review Board on October 22, 2021 (study number 2021H0329). We used the Standards for Reporting Qualitative Research ( O’Brien et al., 2014 ) to formalize our reporting ( Appendix A ). Participant recruitment Physical therapists were recruited to participate in this study as a nested convenience sample from the aforementioned survey study which utilized purposive sampling ( Crick et al., 2023 ). Full details for participant recruitment and methods for that study are described elsewhere ( Crick et al., 2023 ). Briefly, in order to participate in the survey, participants were required to be licensed to practice as a physical therapist or physical therapist assistant in a state or territory of the US and either self-report (1) practicing >50% of clinical time in the acute care setting currently or (2) having significant experience practicing in the acute care setting and are now involved in leadership, academia, or research. Acute care PT practice was operationally defined as hospital-based inpatient clinical care as the primary practice setting for a physical therapist (>50% of clinical time). All participants who affirmed their willingness to be contacted for further research participation and provided an e-mail address were considered for the current qualitative study. Each of these potential participants was then paired with a single number and a random number generator was used to select participants at random. This procedure was completed to maximize the potential for diverse viewpoints without researcher bias influencing individual participant selection. Upon selection, groupings of five participants were each contacted individually via electronic mail soliciting their participation and were informed that a $10 gift card would be provided after interview completion as an incentive to participate. Informed consent was obtained electronically and interviews were then scheduled and completed by a single researcher (JPC). Once each group of five participants either completed the interview or declined to participate, the process would begin again with a new grouping of five randomly selected participants. Non-response was considered as declining to participate to respect survey participant privacy. Data collection We developed a semi-structured interview guide following data analysis from the survey study and incorporated relevant inner setting constructs from the CFIR, in alignment with the research question and planned interpretive description ( Thorne, 2016 ). Interview prompts were created to investigate the most relevant findings from the survey regarding fall prevention practice among acute care physical therapists while also further exploring the role of contextual factors in preventing falls among hospitalized adults. The interview guide underwent iterative refinement through a collaborative process involving content experts with significant research and clinical experience across multiple disciplines, such as PT, occupational therapy, and medicine. The collective research expertise of this group spanned areas including qualitative research, mixed-methods research, implementation science, and improvement science. The final interview guide is available in Appendix B . All interviews were conducted between February and June of the year 2022, completed in a private virtual meeting space, and audio recorded using an encrypted, secure electronic video conferencing software (Zoom video communications, Inc. 2021). An artificial intelligence generated transcript was created from the audio recording then validated and edited by a human to ensure accuracy of the transcript and that all personal identifiers were removed. We determined a priori that recruitment would cease once apparent data saturation had been reached ( Saunders et al., 2018 ). Data saturation was defined as the point at which no new information was observed across interviews to further address the research question ( Saunders et al., 2018 ). Thus at the conclusion of each grouping of completed interviews, apparent themes were discussed between the primary interviewer (JPC) and senior researcher (CQY). Data analysis Recognizing the dynamic nature of preventing falls in hospitals and considering the intent of this study to understand the perspective of physical therapists on contextual factors influencing their practice, we developed an analytic framework by aligning the inner setting domains from the CFIR (which informed the interview guide) with the Multi-Systemic Fall Prevention Model for hospitals ( Figure 1 ) ( Choi et al., 2011 ). This robust model was developed based upon systematic review to inform the development of a sensible fall prevention strategy. Developing an analytic framework ensured an appropriate theoretical scaffolding for our analysis that was based in the literature ( Thorne, 2016 ). Figure 1. Open in a new tab Alignment of the inner setting domain of the consolidated framework for implementation research (CFIR) and model components of the multi-systemic Fall prevention Model. We conducted a collaborative qualitative data analysis using the constant comparative method in phases ( Richards and Hemphill, 2018 ). This analytic approach aligned with our epistemological and axiological stances, allowing iterative analysis that fosters co-construction of meaning and respects the diverse values and experiences of participants. Given our interpretivist epistemology, this approach facilitated a dynamic process where researcher-participant perspectives could interact and evolve through ongoing comparison and reflection. The constant comparative method enabled us to identify patterns while remaining attentive to the contextual variations inherent in participants’ experiences, supporting the development of nuanced understandings of fall prevention practices. Following familiarization with the data and analytic framework, the first phase proceeded inductively with open coding by two independent coders (JPC, GH). After open coding of the first transcript, the reviewers met to calibrate expectations, begin to develop a codebook, and discuss researcher memos ( Richards and Hemphill, 2018 ). The coders continued to meet following the coding of every three transcripts to iteratively refine the codebook, discuss emerging themes, and discuss researcher memos. Following each of these meetings, the evolving codebook and emerging themes were discussed with a senior peer debriefer to resolve any disagreements or apparent inconsistencies ( Lincoln and Guba, 1985 ). The updated codebook was then applied to the next round of three transcripts. This process was repeated until all transcripts were openly coded. After all transcripts had been openly coded, the two coders met to develop categories incorporating existing codes. Following categorization, the coders returned to each transcript to re-code the data deductively with the developed categories and the three model components from the Multi-Systemic Fall Prevention Model for hospitals. Following this final coding process, themes were determined and defined through discussion. Researcher reflexivity As this research proceeded from an interpretivist epistemological perspective, considering the role of the researcher in the dynamic interpretation of the phenomena in question is critical ( Malterud, 2001 ; O’Brien et al., 2014 ). Reflexivity was considered throughout the design and implementation of the research study including explicitly through researcher analytic memos completed during the process of coding and analysis. While conducting this study, the primary researcher (JPC) was a practicing acute care physical therapist and PhD student. In addition to acute care clinical practice, he also has experience conducting research regarding both falls prevention and PT. The second coder for this research project was an undergraduate student research assistant who had also been accepted to a Doctor of Physical Therapy program but had not yet begun graduate coursework (GH). His prior research experience included coding for qualitative research. The peer debriefer was an experienced researcher with expertise in multiple methodologies including qualitative research (CQY). She also has clinical experience as a physical therapist though she is no longer in active clinical practice. At the initiation of the study all three researchers affirmed that falls remained a widespread problem in hospitals, that physical therapists are commonly consulted for patients deemed at risk for falling, yet little was known about hospital-based PT practices related to fall prevention. Strategies to enhance trustworthiness Our approach to ensuring trustworthiness – defined by dependability, confirmability, transferability, and credibility – was grounded in the established technique of collaborative qualitative data analysis as described by Richards and Hemphill ( Guba, 1981 ; Lincoln and Guba, 1986 ; Richards and Hemphill, 2018 ). To ensure credibility of findings we used negative case analysis as part of our constant comparative methods as well as peer debriefing ( Lincoln and Guba, 1985 ; Richards and Hemphill, 2018 ). For all interviews we sought a thick description to understand not only the perspectives of the therapists but also their professional background, including the hospital context in which they practice. To maximize transferability, our findings are developed from this thick description. To enhance the study’s dependability, all transcripts were co-coded, and the emerging codebook, categories, and themes were discussed with a peer debriefer ( Richards and Hemphill, 2018 ; Shenton, 2004 ). Throughout the project implementation we maintained an audit trail detailing decisions related to the methods, analysis, and results to ensure confirmability of findings ( Miles and Huberman, 1994 ). Results Participants Fifteen total potential participants were contacted directly via electronic mail to participate. Of these, 10 interviews were conducted at which time data saturation was reached. Interviews lasted between 28 and 58 minutes [mean (SD) = 40.4 (10.6)]. Seven participants were female and participant ages ranged from 31–76 years of age [mean (SD) = 49.5 (14.8)] ( Table 2 ). Total years of practice experience for the sample ranged from 4 years to 52 years [mean (SD) = 23.7 (15.4)]. Three participants reported their entry level PT degree as a Doctorate, two as a Master’s, four as Bachelor’s, and one as a certificate. At the time of interview, five participants practiced in community hospitals, four in level one trauma centers, and one in a level two trauma center. Of the 10 participants, 4 had additional leadership roles within their organization. All participants reported active membership in the American Physical Therapy Association (APTA). Table 2. Participant characteristics. Participant Number Age Sex Years in practice Entry-level PT degree APTA Member? Hospital type Additional roles PT1 56 F 28 BS Yes Community Yes PT2 76 M 52 Certificate Yes Level 1 trauma Yes PT3 43 F 18 MPT Yes Level 1 trauma Yes PT4 37 F 13 DPT Yes Community No PT5 42 M 19 MPT Yes Level 2 trauma No PT6 70 F 44 BS Yes Community No PT7 53 F 30 BS Yes Community No PT8 51 M 23 BS Yes Level 1 trauma Yes PT9 31 F 6 DPT Yes Level 1 trauma No PT10 36 F 4 DPT Yes Community No Open in a new tab Categories and themes derived Our codebook was established after conducting open coding of the first seven transcripts and was subsequently applied to the remaining three, as no additional codes were required. Seven categories were developed from the codebook: mobility promotion facilitators, mobility promotion barriers, equipment, guidelines, patient factors, PT effectiveness, and PT interventions. Following deductive coding of all 10 transcripts, three primary themes and ten subthemes were derived ( Figure 2 ). Figure 2. Open in a new tab Three primary themes and associated ten subthemes describe the perspectives of acute care physical therapists on fall prevention and describe how the hospital context influences practice patterns and effectiveness of PT interventions. PT = Physical therapy Theme 1: Mobility promotion is central to fall prevention From the perspective of physical therapists, the most critical principle for widespread patient fall prevention during and following hospitalization is the mediating factor of system-wide mobility promotion ( Figure 3 ). Participants uniformly described that fall prevention for hospitalized patients requires a robust and consistent culture of mobility that is adopted and implemented by the entire multidisciplinary team. Figure 3. Open in a new tab Explanatory model for the mediating role of system-wide mobility promotion and the positive moderating role (+) of acute care physical therapy to contribute to reduced patient falls. Contextual factors exhibit negatively moderating influences (−) on the independent, mediating, and moderating variables influencing their implementation and effectiveness. You have to reframe [fall prevention] to more of, let’s focus on the mobility of the patients versus the stigma of how many falls this unit has had. Because that’s going to be where you’re going to be more successful versus creating this fear culture of not getting people up. That’s just going to lead to more falls. (PT9) While participants believed that physical therapists are important participants in this multidisciplinary team, there was a clear recognition that successful mobility promotion, and thus fall prevention, requires substantial nursing commitment. I don’t think I would even call it fall prevention, because I think when you focus on falls, then that’s going to lead to more like negative things like, “Well, let’s just keep people in bed, let’s just turn on all the alarms. And if they don’t get up then they can’t fall.” And instead focusing it more on like a nursing driven mobility initiative. Because if you’re going and you’re getting patients up every three hours to get them onto the toilet, then they’re not going to try to get up on their own to go to the bathroom when you’re not there, because you’re already doing it. So, I think I would focus [fall prevention] more on that kind of positive side of it with a mobility driven, nursing led initiative. (PT9) Physical therapists, participants noted, provide essential education and recommendations to nursing staff to enhance safe patient mobilization during hospitalization. This education may include specific needs for use of durable medical equipment (DME), for creating shared mobility goals for a particular patient, or for addressing a particular impairment that necessitates a specialized method for safely promoting gait or transfers. Participants referenced their understanding that the medical literature supported maintaining patient’s physical capabilities through targeted mobility promotion is effective in preventing falls among hospitalized patients. We’ve got a lot of research over the past 10 or 15 years of just general mobility programs working, why reinvent the wheel? The problem is just getting the bodies to do it and getting the right staff mix, the right people in the right place at the right time. I think that’s the biggest challenge. (PT3) Importantly, the participants emphasized that additional fall prevention interventions, such as alarms or patient safety sitters, may be incorporated into a comprehensive fall prevention strategy, but they should not substitute for consistent mobility promotion. Six primary contextual factors were identified that limit the optimal practice of physical therapists and other disciplines, including nursing staff, in implementing fall prevention and mobility promotion ( Figure 3 ). These factors include time constraints, institutional priorities, patient volume, staff availability, lack of available equipment, and the physical environment. Subtheme: Nursing care guidelines are commonly mobility limiting Despite consistently recommending mobility promotion for preventing patient falls, participants characterized nursing care guidelines as promoting sedentariness. Most hospitals require that nurses complete a formal fall prevention screening measure on a regular basis, such as each shift. The results of the screening measure commonly correspond to nursing interventions aimed at preventing patient falls. Participants considered these interventions, examples including bed or chair alarms, manual releasing lap belts, patient safety sitters, and specialized low-rise beds that hinder easy standing, to be reliably implemented yet almost uniformly mobility limiting. Concerningly, participants noted that once restrictive interventions were placed, they were less likely to be removed. People are reluctant to remove alarms on somebody that’s already alarmed, even though that they’ve [improved] above this threshold. (PT5) One exception described by two participants was a system-wide initiative, the Johns Hopkins Mobility Goal Calculator ( Klein et al., 2018 ; McLaughlin et al., 2022 ), in which a functional screening measure completed by nursing suggested a daily patient mobility goal. These two participants connected this initiative to reduced patient falls, though this was described as separate and in addition to the typical fall prevention screening measure. Subtheme: Physical therapy moderates mobility promotion to prevent falls Multidisciplinary mobility promotion as a central tenet to fall prevention requires considerable nursing commitment given their round-the-clock patient support role. Participants recognized the central role of the nursing staff in fall prevention and described physical therapists as serving in a moderating role. That is, therapists augment mobility promotion and fall prevention efforts ( Figure 3 ). Specifically, therapists enhance mobility promotion and fall prevention by providing education in safe mobility techniques and in optimal mobility targets to both nursing staff and patients themselves. In addition, therapists educate patients in fall prevention strategies specific to patient impairments and diagnoses that are useful for preventing falls both during and following hospitalization. I think in the acute care setting it would be education of staff … Really ensuring that the nursing staff are aware of the safest and most effective ways to move with the patients and to ensure that the patient is getting out of bed. But also doing it faithfully because I believe that the carryover is more consistent with the nursing staff as opposed to the patient needing to remember. (PT10) Subtheme: Investment in novel interventions overshadows established mobility practices Participants did not believe that novel interventions were required to prevent patient falls in their hospitals. Rather, they perceived that consistent implementation of known effective interventions, especially consistent mobility opportunities surrounding toileting, would result in reduced falls. If we would do the things we already know, faithfully and consistently, things would get to be a lot better. If a novel program meant that there would be better staff compliance, that would be great. But I think we’re not yet at a place where we’re consistently doing all the things we know we could be doing to reduce falls. And so if we would do that as a starting place, things would get better. (PT2) Two prominent contextual barriers, lack of available staff and lack of necessary equipment, limit offering patient mobility opportunities. This may result in patients being offered the chance to use a bedpan to toilet instead of a bedside commode if either a bedside commode could not be readily accessed or if enough personnel were not available to safely complete a transfer in time. Interestingly, participants described hospital investments in novel interventions aimed to reduce patient falls with varying degrees of perceived success. For example, several participants mentioned investing in color-coded socks to indicate patient fall risk levels while others discussed using patient safety sitters, either in-person or via a monitored video feed. They implied that increasing available bedside equipment and increasing staff for hourly patient rounding would be a better investment to reduce fall rates. Theme 2: Systemic factors limit physical therapist fall prevention practice The aforementioned contextual factors all contribute to reduced ability of physical therapists to practice optimally for fall prevention. Although the influence of these contextual factors varied between hospitals, they were consistently represented in all interviews and the influence of these contextual factors is reflected throughout the subthemes below. Participants remarked that considerable variability exists in fall prevention practice both between institutions and even amongst therapists within their own department. The first variability I see is do [physical therapists] even [screen for falls]? That’s my first observation is it’s not consistent that we even do it at all. We may, in the back of our heads or talking to the nurse, maybe it comes to mind, but I didn’t see consistency in even addressing it with the patient. (PT2) This variability was perceived as problematic, as was the lack of inter-therapist communication about specific patient needs. Participants noted concern that patients receive variable education and intervention from physical therapists because of a lack of direct handoffs. Sometimes communication between our team is not optimal. We often don’t have a lot of carryover, I work weekends…And then there are other staff members during the week. So, I have to rely on my colleagues reading my notes from the weekend because we don’t have a conversation about it. (PT10) Interestingly, and consistent with the results of the survey study that preceded this investigation ( Crick et al., 2023 ), clinical experience seems to minimize the impact of some contextual factors on fall prevention practice for more experienced therapists. More experienced participants described a clearer understanding of their role and a focus on what they could influence rather than aspects beyond their control. However, it remains unclear whether the fall prevention practices of experienced clinicians truly differ from those of their less experienced counterparts or if, instead, they have simply become more adept at managing and accepting the limitations imposed by systemic factors. I think it’s easier for me now to know which ones I have control over and which ones I don’t. Like the physical environment I can control to an extent by setting things up before I even get the patient out of bed …s Things like that I can control a little bit better versus how many therapists are on staff for the day, and how many patients I have to see, and how many phone calls I get from nursing staff or case managers … Those things are not in my control. (PT9) Subtheme: Deficiency in outcome measure utilization In contrast with nursing guidelines that are robustly implemented, participants described a concerning lack of fall prevention outcome measure use by physical therapists. Despite explicitly favoring clear guidelines for practice, participants described a paucity of transparent expectations in their organizations as it relates to fall prevention practice. Not everyone does the same tests and measures … Or some people don’t even do functional measures. I know that’s another thing that in the acute care setting a lot of people don’t do. It’s more just like eyeballing the patient, looking at their assist levels and saying, “Oh yeah, this patient needs more assist so they’re at risk for falls,” versus putting an objective measure to it. (PT9) A commonly reported barrier to implementing these expectations is lack of administrative oversight within the rehabilitation department. This manifested itself in two ways for participants. First, there was a belief that increased administrative oversight may result in dissatisfied therapy staff which may be problematic due to existing difficulty maintaining full staffing. I think standardized protocols are only as good as the administration that you have and the management that you have and how you’re going to uphold those. Because if you want your standardized protocols to be held in place, you’ve got to make sure that they’re being performed in a standard way … In the environment that we’re living in right now, there’s not a lot of accountability. I think a lot of people are scared to hold people accountable because they’re afraid that people will leave and quit. (PT3) Second, participants remarked that other initiatives have failed due to lack of frontline therapist buy-in. This was the result of therapists not being involved in the development of guidelines and thus implementation was cumbersome and the change not adopted. Having a standard policy or practice but not having any follow through that it is actually being implemented. Why add something else if the current model isn’t being followed through with? And it’s not that the staff don’t want to follow through, they don’t have the resources to follow through. (PT5) It’s really a time thing. Nobody has enough time to really spend with their patient … I think most hospitals actually have fall prevention policies and principles in place, but they don’t give personnel the time to effectively implement them. (PT6) Subtheme: Lack of consistent physical therapy treatment Participants noted that fewer and fewer follow-up visits are offered to patients following the initial evaluation, primarily due to the contextual limiters of high patient volumes and less therapy staff. Due to this, therapists adjust the focus of their intervention with the anticipation that the patient may not be seen by a physical therapist again prior to discharge. I always instruct therapists to treat the patient, every single treatment, treat them like it’s the last time you’re going to see the patient. Because if you go in treating, [thinking] I’m going to see them two more times, you don’t anticipate what you can address [now]. And so being proactive, as opposed to reactive, is always good. (PT1) This reality is exacerbated by time limitations, often resulting in a lack of directly focused fall prevention assessment, education, or intervention being provided to patients. You’re seeing patients basically just for evaluations and then feeling like you can’t even get back to them to do treatment sessions because you don’t have the staff. It makes it difficult to feel like you can provide that quality care and spend the time in each room because you have so many other patients. (PT9) Moreover, the expectation that therapists are “productive” further exacerbates the perception that time is limited due to high patient volumes. The pressure to be productive has impacted what therapists give attention to with patients because they’re under the gun to move to the next patient. And so in some patients, falls prevention is like icing on the cake and we’re still working on making the cake … Falls prevention and education could be way down the list of things. (PT2) More experienced therapists tended to agree that this limited time and lack of treatments has changed during their careers. It also has contributed to fall prevention efforts being sacrificed in favor of expediency to see more patients. No back when I first started, and I’ve been a therapist for over 30 years now, there was more staff so you were able to provide more to each patient and spend a little bit more time with them and see each patient compared to now. To me now it’s try to do more with less, but just doesn’t quite work out that way. (PT7) Subtheme: Competing institutional and therapist patient care priorities The lack of hospital PT treatment following the initial evaluation is further exacerbated by a discordance between patients who therapists believe should be prioritized for treatment and patients who hospital administrators believe should be prioritized. This revealed a conflict about system-level priorities, such as influencing length of stay, and patient-focused priorities, such as limiting hospital-associated deconditioning and reducing patient fall risk. I am butting heads with my direct supervisor about this because they have a high, medium, low priority and they rank these high priority people as planned orthopedics and stroke. But then what tends to happen is these [are] higher level, less complex, “walkie-talkie” types. And that’s what’s on our caseload all the time. And what they consider a low priority … is prolonged hospital stay, a complex medical case … And I keep saying, my feeling is a patient with a potentially prolonged hospital course is considerably complex and requires our services the most. (PT10) Further exemplifying the competing priorities is the concept that participants defined as “inappropriate referrals.” These were PT consultations that participants deemed unnecessary and contributed to high patient evaluation burdens, thus diluting available therapists to complete treatments. Additionally, the lack of routine nursing mobilization was perceived to contribute to low value PT consultations. Making sure that patients are getting orders for therapy if it’s appropriate [and] not putting in orders for therapy where it’s not appropriate. Just because someone hasn’t been out of bed in three days doesn’t mean they need therapy. It means that nursing needs to get them out of bed and see if they can mobilize, or they shouldn’t have ever been left in bed for three days in the first place. (PT9) Theme 3: Physical therapy fall prevention effectiveness is context-dependent Hospital systemic factors not only influence practice patterns but also impact the effectiveness of interventions. Participants noted that therapists adapt their intervention selection to prioritize those they believe will be most effective within the hospital system’s constraints. For example, they prioritize patient education and discharge planning to minimize post-hospitalization fall risks, while focusing on staff education and promoting nurse-led mobilization to prevent falls during hospital stays. I would like to think that that yes, we are making a difference. Whether it’s educating the patient themselves or maybe educating the staff on how to better move this patient if they do need to transfer bed to chair and they’re a tougher patient or get to the bathroom or things like that. So yes, I would like to say that we do make an impact on helping to prevent falls. (PT4) Thus, therapists have adopted practice patterns to align their skills and expertise to maximize their impact on fall prevention given the limitations of the hospital context. So working in acute care, where the turnover is fairly rapid … the way therapists are effective at preventing falls is prescribing a next step. If you see them within 24 hours and they will be discharged 48 hours or so from the time you see them. Really there’s nothing or very little you can do to really impact that change in their stability or balance except say you really need to use a walker, you need to never walk without shoes, you need offsetting shoes, things like practical things, and to recommend a discharge destination or ongoing care to get them set into outpatient or home health. (PT6) Subtheme: Education as a tool to reduce fall risks Participants were clear that the education provided by physical therapists is offered at two levels: to the nursing staff for in-hospital fall prevention and mobility promotion and to the patient for, primarily, fall prevention post-discharge. Both were informed by the initial evaluation with the understanding that there may or may not be additional opportunities to influence a patients fall risk. I would start with education. And I realize that’s a really big intervention, but I think that’s something we’re really good at. And in acute care I think that’s one of the most important tools in our toolbox. Not just education for the patient, but also for the CNAs and nursing. (PT10) The cognitive status of a patient is critical to the effectiveness of patient education, and this cognitive status is subject to change during hospitalization which influences a patient’s risk for falling. The work that PTs perform in helping patients to reduce falls is really identifying a continuum for patients to understand what contributes to their fall [risk], what factors are modifiable regarding falling, and what control that patients have to be able to reduce their falls. So, in a population of patients that is cognizant and can comprehend instruction, that makes a huge difference in the hospital setting. (PT1) The reality that a patient can express their own autonomy by not applying the education provided, and that this may result in increased falls, was also reflected by participants. Are we ever going to be able to completely prevent 100% of the falls? No. Because no matter how much education we provide, at the end of the day, a patient’s going to go home and some of them are going to do whatever they want anyway, no matter how many times we tell them this might not be the safest way. (PT4) Subtheme: Safe discharge planning reduces fall-related readmissions Participants agreed that because hospital lengths of stay tend to be short and PT treatment is not always available for patients, safe discharge planning is a critical component of effective fall prevention for acute care physical therapists. Further, participants suggested that safe discharge planning directly reduces fall-related readmissions. [On the most effective interventions to reduce patient falls.] “Just providing the best recommendations, I think, for discharge in terms of what level of care would be the best for them to ensure their safety and that they don’t have a fall at the next level of care.” (PT9) Conversely, participants also reported that patients who eschew physical therapist discharge recommendations are more likely to be readmitted either due to falls or an inability to care for themselves. A lot of patients and family members just want to go home. They don’t want to go to rehab, whether it be an inpatient rehab facility or a skilled nursing facility. So we’re finding even though we may be recommending a certain level of post-acute care for therapies, the patient and their families are choosing to go home instead. And you can only provide so much education and training when someone really does require that skilled need, hence the recommendation. So I think I’ve seen that a lot more frequently with people going home, not succeeding, falling, or, you know, maybe getting more ill or just not even able to get up out of bed to the bathroom, and failing to thrive and having to come back to the hospital for placement. (PT9) Subtheme: Hospital policy shaping via therapist committee involvement Participants frequently described the benefits of having physical therapist representation on hospital-wide fall prevention committees to help shape policy for mobility promotion and fall prevention. By providing expertise to influence hospital policies, participants felt physical therapists could have a significant indirect effect on reducing patient falls. I think that would be a wise and useful use of a physical therapist’s knowledge to assist [on the committee] if these falls are resulting in readmissions. Why not have a physical therapist doing a review to see how we can better address and mitigate those falls downstream? (PT5) While participation in committees was recommended, participants returned the focus of the committees to the multidisciplinary team, further clarifying the position of physical therapy as a key moderator in the process of reducing patient falls. There has to be buy-in or ownership by nursing and administration to really make any kind of a protocol for fall risk reasonable. Therapists should be on every fall risk reduction or safety committee in any hospital. But I think it’s a mistake to think that rehab should be the key player. (PT6) Subtheme: Acknowledging the inevitability of some falls Despite widespread efforts to prevent falls and participants’ belief in the effectiveness of PT to contribute to reduced falls, they consistently described that some patient falls are inevitable. Participants situated unavoidable falls primarily into two categories: those associated with patient autonomy and those associated with acute medical conditions, including the effects of medications. Respecting patient autonomy was described as an ethical imperative that must be upheld. [Patients are] grown adults who have lived a lifetime without us. And they are independent, and they are stubborn, and they are confident, and they are sometimes in denial about their medical conditions … You cannot solely, without becoming more of a dictatorial practice, you cannot solely indicate that patients are not going to fall. (PT1) Changing medical conditions and the influence of medications also result in some inevitable patient falls. I think in some circumstances there are just going to be some issues that, whether it’s medically, whether it’s because of medication, or whether it is because of patient’s own intrinsic factors, that we just can’t [prevent a fall]. (PT3) Finally, some participants pointed out that while promoting mobility could lead to an increase in falls, this should not necessarily be seen as a negative outcome. They emphasized that the benefits of increased mobility, which is crucial for patient health and avoiding disablement, far outweigh the potential risks of falls. Therefore, falls in this context could be an inevitable part of improving patient mobility and should not detract from its overall positive impact. As we decrease length of stay of those patients, I think that without therapy involvement the risk would go up. I think my perception is we help mitigate fall risk more [for] the more disabled, more impaired patients. Just because we are helping assist them in restoring function and educating and having staff try to mobilize them appropriately in a safe manner. (PT5) Discussion The purpose of this study was to explore and understand the perspectives of acute care physical therapists on fall prevention practices within hospital settings while also investigating how specific contextual factors influence their practice patterns and the perceived effectiveness of PT interventions. Our analysis yielded three themes and ten subthemes. Collectively, these themes provide a comprehensive understanding of physical therapists’ perceptions of fall prevention in hospitals and their role in preventing patient falls. It is interesting to note how physical therapists, commonly consulted for patients with mobility impairments or who are at risk for falling, perceive themselves as beneficial but not central contributors to fall prevention. This perspective aligns with the Multi-Systemic Fall Prevention Model which posits that effective fall prevention strategies leverage assessment and interventions across three primary domains: technology, care processes and culture, and physical environment ( Choi et al., 2011 ). Our results suggest that physical therapists prioritize care processes supporting patient mobilization with an emphasis on enhancing a culture of patient mobility. Moreover, physical therapists recognize the multi-faceted nature of patient falls and agree that individual interventions are unlikely to result in meaningful reduction of falls ( Choi et al., 2011 ). Study participants reflected a consensus opinion that mobility promotion, rather than mobility restriction, aligns with evidence-based practice for fall prevention. Recent literature supports the logic that increased mobilization opportunities leads to both improved functional status and reduced patient falls ( Kissane et al., 2023 ). Furthermore, international guidelines for fall prevention strongly recommend safe mobility promotion within the constraints of individual physical impairments (Montero-Odasso et al., 0000). Conversely, participants expressed a conviction that the most faithfully implemented fall prevention interventions in hospitals tend to be mobility restricting. Fall risk assessments completed by nurses were described as routine practice, with higher risk patients receiving more mobility limiting interventions. A large retrospective analysis of hospitalized patients supports the perspective that those identified as having a higher risk of falling are significantly less likely to mobilize, even if they possess the physical capability ( Capo-Lugo et al., 2023 ). Recent recommendations further support the belief held by physical therapists that fall prevention plans should be tailored to individual patients, target modifiable risk factors instead of relying on patient risk gradients, and emphasize opportunities for mobility ( McVey et al., 2024 ). Unfortunately, the hospital contextual factors of limited staffing and high patient volumes are significant barriers to widespread multidisciplinary mobility promotion according to physical therapists. The literature supports the belief among both therapists and nurses that increased patient mobilization requires an increased workload for nurses ( Crooks et al., 2024 ; Hoyer, Brotman, Chan, and Needham, 2015 ; Silcox and Doucette, 2023 ), yet some qualitative feedback from nurses suggests that increased patient independence results in a decreased workload ( Hoyer, Brotman, Chan, and Needham, 2015 ). Additionally, lack of confidence in providing general mobilization assistance is a consistently reported barrier amongst nurses ( Crooks et al., 2024 ; Silcox and Doucette, 2023 ). The combination of time constraints due to other responsibilities and a lack of confidence likely contributes to patient ambulation being the most frequently omitted nursing intervention ( Kalisch, Landstrom, and Williams, 2009 ; Kalisch, Tschannen, and Lee, 2012 ). While dedicated nurse education on the benefits of patient mobility and safe intervention techniques can effectively enhance nurses’ beliefs about the importance of patient mobility, it has proven ineffective in implementing increased patient mobilization ( Silcox and Doucette, 2023 ). A primary focus of this study was to explore how contextual factors influence the practice of PT and the effectiveness of PT interventions. Six contextual elements associated with practicing in a hospital setting were consistently described by participants: time limitations, institutional priorities, high patient volumes, lack of available staff, limited equipment availability, and the physical environment. Each of these influenced the practice of PT related to patient fall prevention, often negatively impacting physical therapist practice. Our results that the hospital setting plays a critical role in the clinical decisions made by physical therapists are consistent with those from a 2016 systematic review of the qualitative PT literature ( Lau, Skinner, Lo, and Bearman, 2016 ). The finding that contextual barriers might prevent therapists from implementing specific fall prevention interventions altogether is particularly worrying, as this may compromise both patient safety and the effectiveness of PT. Moreover, Smith et al identified clinical experience as a modifiable factor enabling therapists to navigate the complexity of the hospital environment more effectively ( M. Smith, Higgs, and Ellis, 2007 ; Smith, Joy, and Ellis, 2010 ). This was expanded upon in our results as practice experience aided therapists’ abilities to discriminate what they could control, ultimately improving fall prevention practice. Compounding this issue further is the frustration stemming from institutional mandates that require physical therapists to prioritize certain patients – choices that often conflict with therapists’ own assessment of patient needs. This tension is also consistent with prior study as Lopopolo noted that infringing upon professional autonomy may result in discontented therapists who exhibit less commitment to their organizations ( Lopopolo, 2002 ). Despite considerable contextual limitations to fall prevention practice among physical therapists, participants uniformly agreed that PT is effective in preventing patient falls during and following hospitalization. As the hospital context significantly influenced therapist decision-making, participants described how therapists accommodated to the environment to maximize the effectiveness of chosen interventions within the systemic constraints. A primary focus on patient education for fall prevention among hospitalized patients is supported by high quality studies ( Haines et al., 2011 ; Heng et al., 2020 ; Lee, Pritchard, McDermott, and Haines, 2014 ; Morris et al., 2022 ) and has been demonstrated to be cost effective ( Haines et al., 2013 ). Importantly, however, the method of education and patient selection are critical variables to consider for education ( Heng et al., 2020 ). Multimedia supported education has been demonstrated to be more salient to cognitively intact patients ( Haines et al., 2011 ), better helping reach patients who may otherwise believe that fall prevention education was not relevant to them ( Heng et al., 2021 ). Our study participants described not only providing patient education, however, but also education in fall prevention and mobility promotion to multidisciplinary staff members, particularly nurses. Staff education on fall prevention, in addition to tailored patient education, has also been demonstrated to be effective for fall prevention among hospitalized patients ( Hill et al., 2015 ). In addition to education, participants described that, given the contextual constraints, the most effective strategy for fall prevention among physical therapists is conducting assessments and making discharge recommendations. The belief that physical therapist discharge recommendations, when followed by patients, results in reduced odds of hospital readmissions is well-supported in the literature amongst diverse patient populations ( Chou et al., 2021 ; Shoemaker et al., 2019 ; Smith, Fields, and Fernandez, 2010 ; Wright et al., 2023 ). The practice of physical therapists making discharge recommendations to lower the risk of readmissions, however, may unintentionally cause an increase in unnecessary consultations, which participants described as “inappropriate referrals.” This issue has been increasingly recognized in recent research ( Martinez et al., 2021 , 2023 ; Patel et al., 2023 ). According to our study’s participants, such referrals complicate their work because evaluations take precedence over treatments in many hospitals. Consequently, the excessive number of consultations impairs physical therapists’ ability to deliver adequate follow-up care. Our results also highlight an interesting dichotomy between the reliable implementation of guideline-based nursing assessments for fall prevention and a distinct lack of formal expectations for physical therapists. Participants strongly supported the idea of setting explicit minimum standards for fall prevention by physical therapists, emphasizing the importance of using validated outcome measures. Their positive stance aligns with ongoing efforts to identify a standard set of outcome measures for acute care physical therapists ( Mayer et al., 2021 ). The primary barriers to routine use of outcome measures according to our participants was the lack of time due to patient volume and a lack of administrative requirement. These barriers are consistent with prior work that described administrative support as a primary facilitator of use of outcome measures and lack of time as a primary barrier ( Smith, Furtado, and Brusola, 2022 ). The results of the current study add important nuance to the results of the survey study that preceded it ( Crick et al., 2023 ). Although survey respondents believe that hospitals prioritize best practices for fall prevention, our findings indicate that physical therapists view mobility promotion as the core practice for preventing falls, yet it is significantly constrained by contextual factors. The finding that less practice experience had a stronger influence on contextual elements limiting fall prevention was clarified by our participants. Specifically, they described their fall prevention practices were enhanced by manipulating contextual elements they could control, such as the physical environment. Finally, the survey revealed that standardized fall prevention practice guidelines were uncommon. Our findings indicate that this scarcity stems from insufficient administrative oversight at the institutional level and limited time available at the therapist level. Limitations This study, while providing valuable insights into the perspectives of acute care physical therapists on fall prevention practices within hospital settings, is not without limitations. The sample size, though sufficient to reach thematic saturation, was relatively small and confined to a specific group of therapists who opted to participate in the original survey and subsequent interviews. This selection bias, evidenced by the fact that all participants were APTA members at the time of their interview, may further limit the generalizability of the findings to the broader population of acute care physical therapists. Additionally, the interpretivist paradigm of this study emphasizes subjective understanding of participants to answer the research questions. While providing depth into individual perspectives, and we were intentional to develop thick descriptions, there is the possibility that other influential systemic factors were not identified by participants. Despite rigorous methods to ensure trustworthiness, transparency, and credibility, the specific wording of questions might also have influenced the responses. It should also be noted that the hospital context and its influence on PT practices can vary widely across different institutions which may affect the relevance and applicability of the results in different settings. Nevertheless, this limitation is partially offset by the diversity of our participants, who represented 10 different hospital systems of different sizes and acuity levels across various regions of the country. Conclusions Our results help clarify the nuanced interplay of contextual factors influencing fall prevention practices among acute care physical therapists. The pivotal role of mobility promotion in reducing patient falls was highlighted, as were the influence of systemic barriers on PT practice. The finding that contextual barriers may preclude therapists from completing specific fall prevention interventions altogether is concerning. This represents a key area for additional research and also underscores the need for explicit minimum standards of practice supported by administrative leaders. Future work exploring administrative and policy changes targeted to facilitate more holistic multidisciplinary fall prevention and mobility promotion efforts are needed to enhance patient safety. Acknowledgments We would like to thank Ella Snead for her assistance in deidentifying and validating the transcripts from audio recordings. Funding This research study was supported by a philanthropic research gift to The Ohio State University development office to be stewarded by Dr. Catherine C. Quatman-Yates and Dr. Carmen Quatman. The funder played no role in the design, conduct, or reporting of this study. James Crick is currently supported by the Agency for Healthcare Research and Quality [T32 hS029590]. Appendix A: Standards for Reporting Qualitative Research Item Number Topic Manuscript Page S1 Title 1 S2 Abstract 2 S3 Problem formulation 3–4 S4 Purpose statement 4 S5 Qualitative approach and research paradigm 5 S6 Researcher characteristics and reflexivity 6 S7 Context 6 S8 Sampling strategy 6–7 S9 Ethical issues pertaining to human subjects 5 S10 Data collection methods 7–8 S11 Data collection instruments and technologies 8 S12 Units of study 6–7 S13 Data processing 8 S14 Data analysis 9 S15 Techniques to enhance trustworthiness 9–10 S16 Synthesis and interpretation 10–27 S17 Links to empirical data 11–27 S18 Integration with prior work, implications, transferability, and contributions to the field 27–32 S19 Limitations 32–33 S20 Conflicts of interest 1 S21 Funding 1 Open in a new tab Appendix B: Semi-Structured Interview Guide Tell me about your hospital system. Probe topics: How long have you practiced in acute care? How long have you held your current position? Is your current practice institution similar to prior experiences? Overall, PTs expressed confidence that their interventions and education are effective in reducing patient falls during and following a patient’s hospitalization. What physical therapy interventions do you believe account for this perceived reduction in patient falls? What education do you believe is most effective to accomplish reducing falls in- and following- hospitalization? There was a wide spread of responses among participants as to whether contextual factors influence their ability to provide optimal fall prevention education/intervention for their patients. Do you believe context influences your ability to do this optimally? Why or why not? ( contextual factors include any elements associated with the hospital setting that influence your daily practice. Examples include culture, communication structures, availability of resources ) Patient fall prevention handouts were reportedly utilized by only a small percentage of respondents. Tell me about how you provide education to your patients regarding fall prevention. To what extent do you believe it is effective? Epidemiologic data suggest that fall-related injuries are among the two or three most common reasons for readmission within 30 days. What do you think about that? Rehabilitation departments are reported to not be limited by their size to diffuse new ideas into practice, and many report departmental level changes in the last one year to improve patient care. Would you agree that this the case at your institution as well? Help me understand how you have seen this done well in your own institution. Please provide any examples of department level initiative to improve patient care. If you were to lead an initiative to optimize practice pertaining to hospital fall prevention, tell me about what you would focus on. Who all would need to be involved? Standardized protocols or practice guidelines in departments commonly do not exist to prevent patient falls, per survey respondents. Tell me your thoughts on the benefits or detriments of having such protocols or practice guidelines. Most respondents agreed or strongly agreed that their hospital prioritizes making improvements to prevent patient falls. Can you give examples of any specific improvement initiatives to prevent patient falls at your institution? A mixed response was received as to hospitals encouraging novel ideas to prevent patient falls. Do you believe novel programs are required? If yes, tell me about novel solutions or interventions to prevent falls. Respondents generally agreed that hospital systems need work to improve fall prevention practices. Do you agree with this at your hospital? Please tell me about any programs underway that you know of that are working to address this. Falls are perceived to be preventable by respondents, and therapists believe they are both capable of identifying risk factors and providing appropriate education and intervention to prevent falls. Yet patients continue to fall. Are you able to help explain this paradox? If not contextual factors influencing our ability to provide the intervention and education, what accounts for our patients continuing to fall? If we as therapists are providing valuable interventions and education to our patients at the individual level, what could be contributing at a larger, systems-level that could explain continued falls? Is there anything else that we did not cover that you would like to add? Footnotes Author note This study was approved by our Institutional Review Board October 22, 2021 (study number 2021H0329). Disclosure statement No potential conflict of interest was reported by the author(s). 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