Context-mechanism-outcome Configurations Research Articles

Telehealth delivery of paediatric rehabilitation for children with neurodisability: A mixed methods realist evaluation of contexts, mechanisms and outcomes.

Teledelivery of rehabilitation services has been proposed as a cost-effective option for supporting children with neurodisability and their families. However, little is understood of the conditions that support uptake of telehealth in paediatric rehabilitation, what is delivered during telehealth or perceptions of its outcomes. The aim of this study was to identify the context, process and outcomes of telehealth for children with neurodisability and their families. A secondary objective was to identify if variations in these aspects of telehealth occurred for Māori, the indigenous people of New Zealand. A mixed-methods, three phase, realist evaluation identified context-mechanism-outcome configurations (CMOcs) of telehealth. In Phase 1, the Determinants of Implementation Behaviour Questionnaire indicated factors affecting practitioner uptake of telehealth (Context). In Phase 2, a casenote audit identified 'practitioner input' during telehealth (Mechanism). Phase 3 interviews with practitioners and parents explored 'parent response' to telehealth and practitioner and parent perceptions of its value (Mechanism and Outcomes). Subgroup analyses for Māori were planned. From Phase 1, practitioners (29/37, 78%) intended to use telehealth; however, few did so regularly (7/37, 22%). Positive experiences of telehealth were described by all practitioners (n = 5) and families (n = 7) in Phase 3. CMOcs explained that practitioners' offering of telehealth occurred when practitioners were confident, valued access to therapy over the familiarity of in-person delivery, and when practitioners used coaching-style communication. Parents were receptive to telehealth when they trusted practitioners, felt listened to and were offered telehealth as a choice. When telehealth occurred, access to therapy was timely and more consistent than in-person delivery. Child outcomes appeared to be positive. Confidence in offering telehealth to Māori was low. Initiatives to improve uptake of telehealth in paediatric rehabilitation should focus on creating conditions for practitioner implementation. Training in telehealth should include engagement with Māori. Adequate workspace and workplace culture change are required if telehealth is to be offered beyond the current 'early adopters'.

Deprescribing medicines in older people living with multimorbidity and polypharmacy: the TAILOR evidence synthesis.

Tackling problematic polypharmacy requires tailoring the use of medicines to individual needs and circumstances. This may involve stopping medicines (deprescribing) but patients and clinicians report uncertainty on how best to do this. The TAILOR medication synthesis sought to help understand how best to support deprescribing in older people living with multimorbidity and polypharmacy. We identified two research questions: (1) what evidence exists to support the safe, effective and acceptable stopping of medication in this patient group, and (2) how, for whom and in what contexts can safe and effective tailoring of clinical decisions related to medication use work to produce desired outcomes? We thus described three objectives: (1) to undertake a robust scoping review of the literature on stopping medicines in this group to describe what is being done, where and for what effect; (2) to undertake a realist synthesis review to construct a programme theory that describes 'best practice' and helps explain the heterogeneity of deprescribing approaches; and (3) to translate findings into resources to support tailored prescribing in clinical practice. Experienced information specialists conducted comprehensive searches in MEDLINE, Cumulative Index to Nursing and Allied Health Literature, Web of Science, EMBASE, The Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials), Joanna Briggs Institute Database of Systematic Reviews and Implementation Reports, Google (Google Inc., Mountain View, CA, USA) and Google Scholar (targeted searches). The scoping review followed the five steps described by the Joanna Briggs Institute methodology for conducting a scoping review. The realist review followed the methodological and publication standards for realist reviews described by the Realist And Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) group. Patient and public involvement partners ensured that our analysis retained a patient-centred focus. Our scoping review identified 9528 abstracts: 8847 were removed at screening and 662 were removed at full-text review. This left 20 studies (published between 2009 and 2020) that examined the effectiveness, safety and acceptability of deprescribing in adults (aged ≥ 50 years) with polypharmacy (five or more prescribed medications) and multimorbidity (two or more conditions). Our analysis revealed that deprescribing under research conditions mapped well to expert guidance on the steps needed for good clinical practice. Our findings offer evidence-informed support to clinicians regarding the safety, clinician acceptability and potential effectiveness of clinical decision-making that demonstrates a structured approach to deprescribing decisions. Our realist review identified 2602 studies with 119 included in the final analysis. The analysis outlined 34 context-mechanism-outcome configurations describing the knowledge work of tailored prescribing under eight headings related to organisational, health-care professional and patient factors, and interventions to improve deprescribing. We conclude that robust tailored deprescribing requires attention to providing an enabling infrastructure, access to data, tailored explanations and trust. Strict application of our definition of multimorbidity during the scoping review may have had an impact on the relevance of the review to clinical practice. The realist review was limited by the data (evidence) available. Our combined reviews recognise deprescribing as a complex intervention and provide support for the safety of structured approaches to deprescribing, but also highlight the need to integrate patient-centred and contextual factors into best practice models. The TAILOR study has informed new funded research tackling deprescribing in sleep management, and professional education. Further research is being developed to implement tailored prescribing into routine primary care practice. This study is registered as PROSPERO CRD42018107544 and PROSPERO CRD42018104176. This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 32. See the NIHR Journals Library website for further project information.

Understanding Realist Reviews for Medical Education.

Understanding Realist Reviews for Medical Education.

Realist Reviews: A Brief How-To.

Realist reviews in medical education are designed to add to our understanding of what intervention works, for whom, how, and in what circumstances. The foundational premise of realism is that interventions work differently in different contexts and for different people.1 Realist reviews add to our understanding of how context and mechanisms relate to educational outcomes, referred to as context-mechanism-outcome (CMO) configurations.The steps below introduce key elements when considering a realist review.Context matters: education programs that are effective in one context may not be effective elsewhere. Educational literature reviews tend to explore if a program works; a realist review seeks to understand how a program works and for whom. A realist review seeks to understand why a program might be effective in some contexts and for some learners but not others, and it is useful when seeking to understand both intended and unintended outcomes.A realist review is theory driven. Researchers will propose an initial program theory (or theories) as a potential explanation for how a program works, which is then refined iteratively as the review progresses. The initial program theory may come from the formal program documentation, education literature, expert stakeholders, and/or the researchers' own experiences. A refined theory is the result of a realist review and would be expected to influence the design and implementation of education programs in the future.2Familiarize yourself with the formal guidelines for conducting a realist review3 and realist review reporting standards.4 Strategically assemble a research team to include both content and realist method expertise. Consider seeking input from a librarian or information specialist. Develop initial program theories through brainstorming, speaking with experts in the field, familiarity with the literature, and initial scoping of literature.Initial scoping of the literature is required before determining the area of focus. Then a formal literature search is undertaken. A later search may also be required to seek out additional studies to refine the program theory as the theory develops. Literature selection is not limited to a particular study design type but is determined by its usefulness and contributions to theory. Literature is sought that provides information about CMO configurations. A document flow diagram is useful to show the number of articles assessed for eligibility and included in the review, with reasons for exclusion at each stage.Literature is assessed for inclusion based on relevance (paper's ability to contribute to theory building or theory testing) and rigor (methods used to generate the data are credible and trustworthy). A realist review does not seek to exclude literature based on the traditional hierarchy of evidence, as multiple methods may contribute usefully to theory building. However, papers judged as low quality may be excluded especially when dealing with large data sets. Alternatively, they may be included to inform understandings of context even if not considered for answering whether a complex intervention is effective. Thus, when studies are deemed low in quality, they may be retained for theory development or for testing in a subsequent realist evaluation.Each manuscript is coded for CMO configurations and for its potential to inform program theory. Both quantitative and qualitative data may be considered relevant and extracted. Deductive and inductive coding are relevant when seeking to understand reasons for positive and negative outcomes. Coding for both positive and negative outcomes enables further exploration of where and why programs might not work and for whom. Data to inform a program theory may be found in any manuscript section, not just the results section. Starting with the outcomes and working backward to identify the mechanism and context can be helpful. Another strategy is to try to articulate the CMO configuration as an “if, then” statement.The purpose of synthesis is to refine the program theory. This may involve testing the initial theory, adjudicating between different theories, or reviewing how the theory holds within different settings. In this process researchers find and align the evidence to demonstrate that particular mechanisms generate particular outcomes. This involves looking for CMO configurations that occur across the literature. Expert stakeholders may again be useful to contribute to building and confirming the program theory.Realist reviews can extend our understanding of how a program works, with statements that make explicit the C and M which will contribute to an educational O. Quantitative and qualitative data, both confirming and disconfirming, from primary studies are sought and used to support the theoretical explanation. This new explanation can inform future educational interventions. Contexts where a program is unsuccessful or mechanisms that are key to success should be highlighted. Please see Box 1 for further resources and Box 2 for examples of realist reviews in medical education.

Realist Evaluation of the "Abiye" Safe Motherhood Initiative in Nigeria: Unveiling the Black-Box of Program Implementation and Health System Strengthening.

Realist evaluation studies have spanned different aspects of medicine, especially in the field of public health. However, very few of these studies explicitly detailed how program implementation triggered outcomes that could strengthen understanding of its effect on Health System Strengthening in specific settings. In low- and middle-income countries, like Nigeria, there is a paucity of realist evaluation studies, despite the implementation of multiple intervention programs and projects in these countries. This article is aimed at unveiling the black-box of program implementation and Health System Strengthening of the "Abiye" Safe Motherhood Program in Ondo State, Nigeria. Specifically, it identified the role of contextual factors in the "Abiye" program in Ondo State, determined the mechanisms that facilitated or constrained outcomes of the "Abiye" program, and developed a Context Mechanism Outcome (CMO) Configuration from which a Middle Range Theory (MRT) can be framed. This was qualitative research structured along with the realist domains (Context, Mechanism, and Outcome). The Initial Program Theory was validated by the qualitative study, after which a new MRT was developed. The study population comprised key stakeholders, secondary stakeholders, and primary stakeholders in the Abiye safe motherhood program. Data was collected through 10 key informant interviews, 28 in-depth interviews, and six focus group discussions sessions. Thematic analysis was used to analyze all the qualitative data collected, and seven themes with 19 subthemes emerged in the study. We identified 13 contextual factors under five principal areas, with most of the factors playing enabling roles, some playing inhibitory roles, while very few played both roles. We elicited eight mechanisms, and some of these facilitated the outcomes, while some constrained the outcomes of the program. Health system strengthening was a key feature of the outcome of the program. We developed a middle-range theory based on the 6 CMO configurations we elicited from the study. Realist evaluation is an iterative process that looks beyond the surface to generate evidence. By applying the realist approach, we generated pieces of evidence that can be adapted for policymaking in public health interventions in LMIC.

How do medical students’ experiences inform their opinions of general practice and its potential as a future career choice?

ABSTRACT Recruitment of general practitioners (GPs) in the UK has been suboptimal. There is a wealth of literature exploring recruitment into general practice and opinions of general practice, set in many contexts. This paper aims to synthesise all the elements and extract mechanisms to explain what works, for whom in what circumstances, to create a comprehensive understanding and highlight potential target areas for improvement to improve understanding and fuel interest in general practice careers. A realist review of literature and contemporary data was conducted in line with RAMESES standards. Analysis and synthesis were aided by NVivo. An initial program theory was developed following discussion with expert informers. Sections of text from included literature relating to program theory were extracted and synthesised into a final program theory using a realist logic of analysis in which recurring Context-Mechanism-Outcome configurations (CMOCs) were identified. Searches identified 27 relevant documents. Twenty recurring CMOCs were extracted, explaining how student perceptions of General Practice were influenced by placement experiences, comments from hospital doctors, medical school faculty, peers, GPs, student perceptions of lifestyle and the media. The GP placement environment plays an important role in the formation of opinions about the speciality. The impact of social influence varies depending on the student’s desire to belong to a reference group and their level of self-monitoring behaviour. The ‘GP lifestyle’ was judged to be compatible with many students’ needs. This realist review provides recommendations on how curricula can adapt to provide an accurate insight into general practice.

How, when, and why do inter-organisational collaborations in healthcare work? A realist evaluation.

Inter-organisational collaborations (IOCs) in healthcare have been viewed as an effective approach to performance improvement. However, there remain gaps in our understanding of what helps IOCs function, as well as how and why contextual elements affect their implementation. A realist review of evidence drawing on 86 sources has sought to elicit and refine context-mechanism-outcome configurations (CMOCs) to understand and refine these phenomena, yet further understanding can be gained from interviewing those involved in developing IOCs. We used a realist evaluation methodology, adopting prior realist synthesis findings as a theoretical framework that we sought to refine. We drew on 32 interviews taking place between January 2020 and May 2021 with 29 stakeholders comprising IOC case studies, service users, as well as regulatory perspectives in England. Using a retroductive analysis approach, we aimed to test CMOCs against these data to explore whether previously identified mechanisms, CMOCs, and causal links between them were affirmed, refuted, or revised, and refine our explanations of how and why interorganisational collaborations are successful. Most of our prior CMOCs and their underlying mechanisms were supported in the interview findings with a diverse range of evidence. Leadership behaviours, including showing vulnerability and persuasiveness, acted to shape the core mechanisms of collaborative functioning. These included our prior mechanisms of trust, faith, and confidence, which were largely ratified with minor refinements. Action statements were formulated, translating theoretical findings into practical guidance. As the fifth stage in a larger project, our refined theory provides a comprehensive understanding of the causal chain leading to effective collaborative inter-organisational relationships. These findings and recommendations can support implementation of IOCs in the UK and elsewhere. Future research should translate these findings into further practical guidance for implementers, researchers, and policymakers.

Realist inquiry: a new way to think about overcrowding interventions.

Physician-focused throughput initiatives are intended to mitigate the effects of emergency department (ED) overcrowding. Our tertiary care academic hospital recently piloted an emergency physician leader role intended to improve throughput. Although a separate experimental evaluation of this initiative was undertaken, it was expected that such an evaluation could not alone provide the necessary information to inform 'how' the emergency physician leader intervention worked. The objective of this study was to conduct a realist evaluation of the emergency physician leader. Realist inquiry utilizes Context Mechanism Outcome configurations to determine the impacts of interventions that are often missed by quantitative analysis. Using a realist perspective, this study aimed to evaluate the emergency physician leader initiative's effects on throughput with the goal of building transferable lessons to the implementation of future interventions. Semi-structured interviews with key stakeholders in the intervention were conducted and analyzed using thematic and template techniques specifically aimed at identifying Context Mechanism Outcomes. 13 interviews were conducted with physicians and nurses who identified contexts and mechanisms which promoted or impeded ED throughput. For example, in situations where there was a clear indication for imaging or management that could not be initiated within the scope of a nursing protocol, the emergency physician leader initiating these orders was felt to promote ED throughput. Conversely, in contexts where there was no nurse available to fulfill early orders, the emergency physician leader's initiation of orders was perceived to impede throughput. This evaluation provides insights into the reasoning and behaviour of individuals involved in the emergency physician leader initiative and provides a systematic approach to unraveling its complex causal pathway. Knowledge of context-mechanism-outcome relationships may help implementers design and measure the impact of future physician-focused throughput interventions.

Do the implementation processes of a school-based daily physical activity (DPA) program vary according to the socioeconomic context of the schools? a realist evaluation of the Active at school program

BackgroundLess than half of Canadian children meet the Canadian Physical Activity (PA) Guidelines, and the proportion is even lower among children living in underprivileged neighbourhoods. Regular PA supports physical, cognitive, and psychological/social health among school-aged children. Successful implementation of school-based daily physical activity (DPA) programs is therefore important for all children and crucial for children who attend schools in lower socioeconomic settings. The purpose of this study is to uncover what worked, for whom, how, and why during the three-year implementation period of a new “flexible” DPA program, while paying particular attention to the socioeconomic setting of the participating schools.MethodsThis study is a realist evaluation using mixed methods for data generation. Longitudinal data were collected in 415 schools once a year during the three-year implementation period of the program using questionnaires. Data analysis was completed in three steps and included qualitative thematic analysis using a mixed inductive and deductive method and chi-square tests to test and refine context-mechanism-outcome (CMO) configurations.ResultsGiving the school teams autonomy in the choice of strategies appropriate to their context have allowed schools to take ownership of program implementation by activating a community empowerment process, which resulted in a cultural shift towards a sustainable DPA provision in most settings. In rural underprivileged settings, the mobilization of local resources seems to have successfully created the conditions necessary for implementing and maintaining changes in practice. In disadvantaged urban settings, implementing local leadership structures (leader, committee, and meetings) provided pivotal assistance to members of the school teams in providing new DPA opportunities. However, without continued external funding, those schools seem unable to support local leadership structures on their own, jeopardizing the sustainability of the program for children living in disadvantaged urban areas.ConclusionBy exploring CMO configurations, we have been able to better understand what worked, for whom, how and why during the three-year implementation period of the Active at School! program. When implementing DPA policies, decision makers should consider adjusting resource allocations to meet the actual needs of schools from different backgrounds to promote equal PA opportunities for all children.

Exploring how, why and in what contexts older adults are at risk of financial cybercrime victimisation: A realist review.

Although older people rarely report being victims of financial cybercrime, there is evidence that older online users are at increased risk. This realist review identified factors leading to older adults' victimisation and reviewed the theory and evidence for interventions to reduce victimisation risks. We developed an initial programme theory from a scoping review and expert stakeholder consultations. We searched electronic databases, references and websites for literature meeting inclusion criteria. We analysed 52 primary and secondary data sources, seeking stakeholder views to develop and refine the programme theory and generate Context-Mechanism-Outcome Configurations (CMOCs) explaining how, why and in what circumstances older adults become financial cybercrime victims; and extrapolated this to consider rational intervention strategies. Our programme theory comprised 16 CMOCs describing how: social isolation, cognitive, physical and mental health problems; wealth status, limited cyber security skills or awareness, societal attitudes and content of scams led to victimisation. Our refined programme theory provides a novel framework to guide future intervention design. Only interventions to enhance older internet users' awareness and skills have been trialled to date. Other theoretically plausible interventions include: offender management programmes, tailored security measures, society-wide stigma reduction and awareness-raising with groups who support older people.

How, for Whom, and in Which Contexts or Conditions Augmented and Virtual Reality Training Works in Upskilling Health Care Workers: Realist Synthesis.

BackgroundUsing traditional simulators (eg, cadavers, animals, or actors) to upskill health workers is becoming less common because of ethical issues, commitment to patient safety, and cost and resource restrictions. Virtual reality (VR) and augmented reality (AR) may help to overcome these barriers. However, their effectiveness is often contested and poorly understood and warrants further investigation.ObjectiveThe aim of this review is to develop, test, and refine an evidence-informed program theory on how, for whom, and to what extent training using AR or VR works for upskilling health care workers and to understand what facilitates or constrains their implementation and maintenance.MethodsWe conducted a realist synthesis using the following 3-step process: theory elicitation, theory testing, and theory refinement. We first searched 7 databases and 11 practitioner journals for literature on AR or VR used to train health care staff. In total, 80 papers were identified, and information regarding context-mechanism-outcome (CMO) was extracted. We conducted a narrative synthesis to form an initial program theory comprising of CMO configurations. To refine and test this theory, we identified empirical studies through a second search of the same databases used in the first search. We used the Mixed Methods Appraisal Tool to assess the quality of the studies and to determine our confidence in each CMO configuration.ResultsOf the 41 CMO configurations identified, we had moderate to high confidence in 9 (22%) based on 46 empirical studies reporting on VR, AR, or mixed simulation training programs. These stated that realistic (high-fidelity) simulations trigger perceptions of realism, easier visualization of patient anatomy, and an interactive experience, which result in increased learner satisfaction and more effective learning. Immersive VR or AR engages learners in deep immersion and improves learning and skill performance. When transferable skills and knowledge are taught using VR or AR, skills are enhanced and practiced in a safe environment, leading to knowledge and skill transfer to clinical practice. Finally, for novices, VR or AR enables repeated practice, resulting in technical proficiency, skill acquisition, and improved performance. The most common barriers to implementation were up-front costs, negative attitudes and experiences (ie, cybersickness), developmental and logistical considerations, and the complexity of creating a curriculum. Facilitating factors included decreasing costs through commercialization, increasing the cost-effectiveness of training, a cultural shift toward acceptance, access to training, and leadership and collaboration.ConclusionsTechnical and nontechnical skills training programs using AR or VR for health care staff may trigger perceptions of realism and deep immersion and enable easier visualization, interactivity, enhanced skills, and repeated practice in a safe environment. This may improve skills and increase learning, knowledge, and learner satisfaction. The future testing of these mechanisms using hypothesis-driven approaches is required. Research is also required to explore implementation considerations.

Advancing a programme theory for community-level oral health promotion programmes for humanitarian migrants: a realist review protocol

IntroductionHumanitarian migrants often suffer from poor health, including oral health. Reasons for their oral health conditions include difficult migration trajectories, poor nutrition and limited financial resources. Oral health promotion is...

Medication optimisation in severe mental illness (MEDIATE): protocol for a realist review

IntroductionSevere mental illness (SMI) is associated with significant morbidity and mortality. People living with SMI often receive complex medication regimens. Optimising these regimens can be challenging. Non-adherence is common and...

Which human factors design issues are influencing system performance in out-of-hours community palliative care? Integration of realist approaches with an established systems analysis framework to develop mid-range programme theory

ObjectiveTo develop mid-range programme theory from perceptions and experiences of out-of-hours community palliative care, accounting for human factors design issues that might be influencing system performance for achieving desirable outcomes...

Unpacking economic programme theory for supervision training: Preliminary steps towards realist economic evaluation.

Cost studies are increasingly popular given resource constraints. While scholars stress the context-dependent nature of cost, and the importance of theory, cost studies remain context-blind and atheoretical. However, realist economic evaluation (REE) privileges context and the testing/refinement of economic programme theory. This preliminary REE serves to test and refine economic programme theory for supervision training programmes of different durations to better inform future programme design/implementation. Our preliminary REE unpacked how short (half-day) and extended (12 week) supervision training programmes in Victoria, Australia, produced costs and outcomes. We employed mixed methods: qualitative realist and quantitative cost methods. Economically optimised programme models were developed guided by identified cost-sensitive mechanisms and contexts. As part of identified context-mechanism-outcome configurations (CMOCs) for both training programmes, we found a wider diversity of positive outcomes but greater costs for the extended programme (11 outcomes; AU$3069/learner) compared with the short programme (7 outcomes; $385/learner). We identified four shared cost-sensitive mechanisms for both programmes (training duration, learner protected time, learner engagement, and facilitator competence) and one shared cost-sensitive context (learners' supervisory experience). We developed two economically optimised programme models: (1) short programme for experienced supervisors facilitated by senior educators ($406/learner); and (2) extended programme for inexperienced supervisors facilitated by junior educators ($2104/learner). Our initial economic programme theory was somewhat supported, refuted and refined. Results were partly consistent with previous research, but also extended it through unpacking cost-sensitive mechanisms and contexts. Although our preliminary REE fills a pressing gap in the methodology literature, conducting REE was challenging given our desire to integrate economic and realist analyses fully, and remain faithful to realist principles. Attention to training duration and experience levels of the facilitator-learner dyad may help to balance the cost and outcomes of training programmes.

A realist review protocol of the role and contribution of the advanced nurse practitioner (ANP) in gastroenterology nursing

Background: The role and contribution of advanced nurse practitioners (ANP) has been well researched and found to be of great value for improving quality patient care and enhancing patient outcomes through education and health promotion. However, the role and the contribution of the ANP to gastroenterology nursing have not been evaluated either nationally or internationally. A review to determine the role and contribution of the ANP in gastroenterology nursing will inform on the contribution of the role and whether the role makes a difference to patient outcomes and cost effectiveness of patient care. Objective: This review aims to investigate the nursing role and contribution of the advanced nurse practitioner in gastroenterology. Furthermore, improved understanding of the underlying causal mechanisms explaining how the ANP role in gastroenterology nursing works, will provide a deeper understanding of how, why, for whom and in what contexts the role and contribution of the ANP to gastroenterology nursing are most successful. Methods: A realist review will consolidate evidence on how, when why and where the ANP role in gastroenterology works or fails through identifying programme theories underlying to the role’s introduction. The following steps will be operationalised; locating existing theories, searching the literature, documenting literature selection, engaging in data extraction and synthesis and refining programme theory. As an iterative approach, review cycles will uncover explanatory and contingent theories through context-mechanism-outcome configurations (CMOCc). Due to the variation in context and mechanisms, different outcomes will be likely across different clinical settings although similar patterns may be identified. Conclusions: Due to the theory-oriented approach of realist reviews, the pragmatic consequences of the review, will lend itself to deeper understanding of how the role and contribution of the ANP in gastroenterology nursing works in practice.

The effectiveness of extended-duration supervision training for nurses and allied health professionals: A realist evaluation

BackgroundTraining helps maintain high-quality supervision and its associated benefits (e.g. reduced burnout, improved care). While studies have previously evaluated extended-duration supervision training programmes, none have treated these as complex interventions so have not employed realist approaches. ObjectivesBuilding on a previous realist synthesis, this evaluation tests and develops programme theory for extended-duration supervision training to answer the question: to what extent does the supervision training programme work, for whom, under what circumstances and why? DesignWe conducted a realist evaluation of a novel state-wide Victorian 3-month supervision training programme including one or two 3.5-h workshops followed by weekly reflexive longitudinal audio diaries (LADs) for up to 12 weeks. MethodsRealist evaluation data comprised 25 entrance interviews with nurses and allied health professionals, 176 LADs (and 29 written diaries), and 23 exit interviews. We employed team-based realist analysis to identify context-mechanism-outcome configurations (CMOCs) to test and develop programme theory. ResultsWe refined four recurring CMOCs from the realist synthesis programme theory, found insufficient evidence for two, and established five new recurring CMOCs. We identified multiple positive outcomes from our extended-duration supervision training programme (e.g. improved supervisor practices) through various mechanisms relating to pedagogy (e.g. weekly reflexivity), supervisors (e.g. engagement), and workplaces (e.g. enabling supervision cultures). Some negative outcomes were reported (e.g. decreased engagement) through various mechanisms (e.g. suboptimal training design). Such mechanisms were thought to come about by diverse contexts including supervisors (e.g. inexperienced/experienced), professions (nursing/allied health), and organisations (supervision-enabled/non-enabled cultures). ConclusionsOur findings extend the realist synthesis programme theory by highlighting various contexts triggering outcome-generating mechanisms. Programme outcomes are maximised through ongoing supervisor reflexivity paying attention to facilitator-supervisor relationships, as well as protected time for supervisors to translate learning into practice.

Context, mechanisms and outcomes of dementia special care units: An initial programme theory based on realist methodology.

BackgroundDementia special care units represent a widely implemented care model in nursing homes. Their benefits must be thoroughly evaluated given the risk of exclusion and stigma. The aim of this study is to present an initial programme theory that follows the principles of realist methodology. The theory development was guided by the question of the mechanisms at play in the context of dementia special care units to produce or influence outcomes of interest in people with dementia.MethodsThe initial programme theory is based on qualitative interviews with dementia special care stakeholders in Germany and a realist review of complex interventions in dementia special care units. The interviews were analysed using content analysis techniques. For the realist review, a systematic literature search was conducted in four scientific databases; studies were appraised for quality and relevance. All data were analysed independently by two researchers. A realist informed logic model was developed, and context-mechanism-outcome (CMO) configurations were described.ResultsWe reviewed 16 empirical studies and interviewed 16 stakeholders. In the interviews, contextual factors at the system, organisation and individual levels that influence the provision of care in dementia special care units were discussed. The interviewees described the following four interventions typical of dementia special care units: adaptation to the environment, family and public involvement, provision of activities and behaviour management. With exception of family and public involvement, these interventions were the focus of the reviewed studies. The outcomes of interest of stakeholders include responsive behaviour and quality of life, which were also investigated in the empirical studies. By combining data from interviews and a realist review, we framed three CMO configurations relevant to environment, activity, and behaviour management.DiscussionAs important contextual factors of dementia special care units, we discuss the transparency of policies to regulate dementia care, segregation and admission policies, purposeful recruitment and education of staff and a good fit between residents and their environment.

STOPP/START interventions to improve medicines management for people aged 65 years and over: a realist synthesis

BackgroundDrug-related problems and potentially inappropriate prescribing impose a huge burden on patients and the health-care system. The most widely used tools for appropriate prescription in older adults in England and in other European countries are the Screening Tool of Older People’s Prescriptions (STOPP)/Screening Tool to Alert to the Right Treatment (START) tools. STOPP/START tools support medicines optimisation for older adults.ObjectivesTo identify, test and refine the programme theories underlying how interventions based on the STOPP/START tools are intended to work, for whom, in what circumstances and why, as well as the resource use and cost requirements or impacts.DesignA realist synthesis.SettingPrimary care, hospital care and nursing homes.PatientsPatients aged ≥ 65 years.InterventionsAny intervention based on the use of the STOPP/START tools.Review methodsDatabase and web-searching was carried out to retrieve relevant evidence to identify and test programme theories about how interventions based on the use of the STOPP/START tools work. A project reference group made up of health-care professionals, NHS decision-makers, older people, carers and members of the public was set up. In phase 1 we identified programme theories about STOPP/START interventions on how, for whom, in what contexts and why they are intended to work. We searched the peer-reviewed and grey literature to identify documents relevant to the research questions. We interviewed experts in the field in our reference group to gain input on our list of candidate context–mechanism–outcome configurations, to identify additional context–mechanism–outcome configurations and to identify additional literature and/or relevant concepts. In phase 2 we reviewed and synthesised relevant published and unpublished empirical evidence and tested the programme theories using evidence from a larger set of empirical studies.ResultsWe developed a single logic model structured around three key mechanisms: (1) personalisation, (2) systematisation and (3) evidence implementation. Personalisation: STOPP/START-based interventions are based on shared decision-making, taking into account patient preferences, experiences and expectations (mechanisms), leading to increased patient awareness, adherence, satisfaction, empowerment and quality of life (outcomes). Systematisation: STOPP/START tools provide a standardised/systematic approach for medication reviews (mechanisms), leading to changes in professional and organisational culture and burden/costs (outcomes). Evidence implementation: delivery of STOPP/START-based interventions is based on the implementation of best evidence (mechanisms), reducing adverse outcomes through appropriate prescribing/deprescribing (outcomes). For theory testing, we identified 40 studies of the impact of STOPP/START-based interventions in hospital settings, nursing homes, primary care and community pharmacies. Most of the interventions used multiple mechanisms. We found support for the impact of the personalisation and evidence implementation mechanisms on selected outcome variables, but similar impact was achieved by interventions not relying on these mechanisms. We also observed that the impact of interventions was linked to the proximity of the selected outcomes to the intervention in the logic model, resulting in a clearer benefit for appropriateness of prescribing, adverse drug events and prescription costs.LimitationsNone of the available studies had been explicitly designed for evaluating underlying causal mechanisms, and qualitative information was sparse.ConclusionsNo particular configuration of the interventions is associated with a greater likelihood of improved outcomes in given settings.Study registrationThis study is registered as PROSPERO CRD42018110795.FundingThis project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full inHealth Services and Delivery Research; Vol. 9, No. 23. See the NIHR Journals Library website for further project information.

Unpacking context in realist evaluations: Findings from a comprehensive review

Realist evaluation is an established approach in evaluation. The main question driving realist evaluation is to uncover how, for whom, and under what conditions an intervention works. This is accomplished by empirically examining the inner mechanisms by which an intervention generates outcomes within a particular context—explicating the underlying context–mechanism–outcome configurations. Despite the central role of context in realist evaluation, systematic knowledge about how context is conceptualized and applied in realist evaluation is limited. Informed by the findings of a comprehensive review, the aim of this article is to unpack how context is conceptualized in realist evaluations, the types of contextual factors examined as part of context–mechanism–outcome configurations, and the methodological challenges experienced by evaluators when examining these in realist evaluations. The article concludes with a discussion of conceptual and practical developments for future applications of realist evaluations.