Programming Theory Research Articles

Strengthening open disclosure in maternity services in the English NHS: the DISCERN realist evaluation study.

There is a policy drive in NHS maternity services to improve open disclosure with harmed families and limited information on how better practice can be achieved. To identify critical factors for improving open disclosure from the perspectives of families, doctors, midwives and services and to produce actionable evidence for service improvement. A three-phased, qualitative study using realist methodology. Phase 1: two literature reviews: scoping review of post-2013 NHS policy and realist synthesis of initial programme theories for improvement; an interview study with national stakeholders in NHS maternity safety and families. Phase 2: in-depth ethnographic case studies within three NHS maternity services in England. Phase 3: interpretive forums with study participants. A patient and public involvement strategy underpinned all study phases. National recruitment (study phases 1 and 3); three English maternity services (study phase 2). We completed n = 142 interviews, including 27 with families; 93 hours of ethnographic observations, including 52 service and family meetings over 9 months; and interpretive forums with approximately 69 people, including 11 families. The policy review identified a shift from viewing injured families as passive recipients to active contributors of post-incident learning, but a lack of actionable guidance for improving family involvement. The realist synthesis found weak evidence of the effectiveness of open disclosure interventions in the international maternity literature, but some improvements with organisation-wide interventions. Recent evidence was predominantly from the United Kingdom. The research identified and explored five key mechanisms for open disclosure: meaningful acknowledgement of harm; involvement of those affected in reviews/investigations; support for families' own sense-making; psychological safely of skilled clinicians (doctors and midwives); and knowing that improvements to care have happened. The need for each family to make sense of the incident in their own terms is noted. The selective initiatives of some clinicians to be more open with some families is identified. The challenges of an adversarial medicolegal landscape and limited support for meeting incentivised targets is evidenced. Research was conducted after the pandemic, with exceptional pressure on services. Case-study ethnography was of three higher performing services: generalisation from case-study findings is limited. No observations of Health Safety Investigation Branch investigations were possible without researcher access. Family recruitment did not reflect population diversity with limited representation of non-white families, families with disabilities and other socially marginalised groups and disadvantaged groups. We identify the need for service-wide systems to ensure that injured families are positioned at the centre of post-incident events, ensure appropriate training and post-incident care of clinicians, and foster ongoing engagement with families beyond the individual efforts made by some clinicians for some families. The need for legislative revisions to promote openness with families across NHS organisations, and wider changes in organisational family engagement practices, is indicated. Examination of how far the study's findings apply to different English maternity services, and a wider rethinking of how family diversity can be encouraged in maternity services research. This study is registered as PROSPERO CRD42020164061. The study has been assessed following RAMESES realist guidelines. This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research Programme (NIHR award ref: 17/99/85) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 22. See the NIHR Funding and Awards website for further award information.

A rapid realist review on leadership and career advancement interventions for women in healthcare

Women represent 70% of the global health workforce but only occupy 25% of health and social care leadership positions. Gender-based stereotypes, discrimination, family responsibilities, and self-perceived deficiencies in efficacy and confidence inhibit the seniority and leadership of women. The leadership inequality is often compounded by the intersection of race and socio-economic identities. Resolving gender inequalities in healthcare leadership brings women’s expertise to healthcare decision making, which can lead to equity of healthcare access and improve healthcare services. With the aim of enhancing women’s advancement to leadership positions, a rapid realist review (RRR) was conducted to identify the leadership and career advancement interventions that work for women in healthcare, why these interventions are effective, for whom they are effective, and within which contexts these interventions work. A RRR ultimately articulates this knowledge through a theory describing an intervention’s generative causation. The Realist and Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) for conducting a realist synthesis guided the methodology. Preliminary theories on leadership and career advancement interventions for women in healthcare were constructed based on an appraisal of key reviews and consultation with an expert panel, which guided the systematic searching and initial theory refinement. Following the literature search, 22 studies met inclusion criteria and underwent data extraction. The review process and consultation with the expert panel yielded nine final programme theories. Theories on programmes which enhanced leadership outcomes among women in health services or professional associations centred on organisational and management involvement; mentorship of women; delivering leadership education; and development of key leadership skills. The success of these strategies was facilitated by accommodating programme environments, adequacy and relevance of support provided and programme accessibility. The relationship between underlying intervention entities, stakeholder responses, contexts and leadership outcomes, provides a basis for underpinning the design for leadership and career advancement interventions for women in healthcare.

Understanding Knowledge Mobilisation between Community Champions and Parents: Evidence from a Community-Based Programme to Support Parents with Young Children.

Community champions have been employed across various settings to disseminate evidence-based public health information. The Building Babies' Brains programme trains champions to work with parents in communities, equipping them with child development knowledge and parental engagement strategies. We explored what makes community champions effective in distributing information to parents, including how the champion-parent relationship and champions' personal characteristics affect information dissemination. Champions included both peers and professionals working with parents in target communities. We administered an online survey (n = 53) and follow-up interviews (n = 14) with champions, with representation from across all training cohorts. We conducted a realist-informed reflexive thematic analysis to generate themes in the data and highlight the contexts, mechanisms, and outcome patterns identified. We observed 15 Context-Mechanism-Outcome configurations across five themes: information sharing opportunities, information relevance, the nature of the champion-parent relationship, interaction expectations, and champion confidence. Our programme theory for how the community champion approach works identified that peer champions focused more on building rapport, modelling behaviours, and being a trusted community resource than direct information transfer. Professional champions, in contrast, showed greater expertise and confidence in discussing parenting practices directly. For both groups, traits such as friendliness and the ability to establish a trusting relationship enhanced effectiveness. This research identifies the impacts of champion role, characteristics, and the champion-parent relationship on the effectiveness of knowledge mobilisation in this context, with implications for training and recruitment of champions. Those using a champion model in comparable settings should ensure that champions have the necessary knowledge, skills, and confidence to engage parents and share information effectively.

How can healthcare organisations improve the social determinants of health for their local communities? Findings from realist-informed case studies among secondary healthcare organisations in England

ObjectivesIncreasingly, healthcare and public health strategists invite us to look at healthcare organisations as not just care providers but as anchor institutions (ie, large community-rooted organisations with significant impact in...

Developing an initial programme theory for a model of social care in prisons and on release (empowered together): A realist synthesis approach.

Many people are living in prison with a range of social care needs, for example, requiring support with washing, eating, getting around safely, and/or maintaining relationships. However, social care for this vulnerable group is generally inadequate. There is uncertainty and confusion about who is legally responsible for this and how it can best be provided, and a lack of integration with healthcare. We used realist-informed approaches to develop an initial programme theory (IPT) for identifying/assessing social care needs of, and providing care to, male adults in prison and on release. IPT development was an iterative process involving (a) an initial scoping of the international prison literature; (b) scoping prison and community social care policy documents and guidelines; (c) full systematic search of the international prison social care literature; (d) insights from the community social care literature; (e) stakeholder workshops. Information from 189 documents/sources and stakeholder feedback informed the IPT, which recommended that models of prison social care should be: trauma-informed; well integrated with health, criminal justice, third-sector services and families; and person-centred involving service-users in all aspects including co-production of care plans, goals, and staff training/awareness programmes. Our IPT provides an initial gold standard model for social care provision for people in prison and on release. The model, named Empowered Together, will be evaluated in a future trial and will be of interest to those working in the criminal justice system, care providers and commissioners, local authorities, housing authorities, voluntary groups, and service-users and their families.

Shared decision-making interventions in the choice of antipsychotic prescription in people living with psychosis (SHAPE): Protocol for a realist review.

Shared decision-making (SDM) has yet to be successfully adopted into routine use in psychiatric settings amongst people living with severe mental illnesses. Suboptimal rates of SDM are particularly prominent amongst patients with psychotic illnesses during antipsychotic treatment choices. Many interventions have been assessed for their efficacy in improving SDM within this context, although results have been variable and inconsistent. To generate an in-depth understanding of how, why, for whom, and to what extent interventions facilitating the application of SDM during antipsychotic treatment choices work and the impact of contextual factors on intervention effectiveness. This review will use realist review methodology to provide a causal understanding of how and why interventions work when implementing SDM during antipsychotic treatment choices. The cohort of interest will be those experiencing psychosis where ongoing treatment with an antipsychotic is clinically indicated. The review will take place over five stages; (1) Locating existing theories, (2) Searching for evidence, (3) Selecting articles, (4) Extracting and organising data and (5) Synthesizing evidence and drawing conclusions. An understanding of how and why interventions work will be achieved by developing realist programme theories on intervention effectiveness through iterative literature reviews and engaging with various stakeholder groups, including patient, clinician and carer representatives. This is the first realist review aiming to identify generative mechanisms explaining how and why successful interventions aimed at improving SDM within the parameters outlined work and in which contexts desired outcomes are most likely to be achieved. Review findings will include suggestions for clinicians, policy and decision-makers about the most promising interventions to pursue and their ideal attributes.

Exploring the impact of early-stage dementia on everyday activities

Introduction: This paper explores the impact that early-stage dementia has on everyday activities from the perspective of people living with dementia, their supporters and occupational therapy practitioners. Method: People living with dementia and their supporters ( n = 10), and occupational therapy practitioners ( n = 21) took part in semi-structured interviews, with transcripts analysed thematically. Findings: Six primary themes were identified across participants, namely: (1) ‘Everybody seems to be different, [but] they are similar’; (2) An awareness of change: ‘Something’s not quite right’; (3) ‘ Changes’ and ‘ difficulties’ associated with complex and unfamiliar activities; (4) Social withdrawal and exclusion: ‘I’ve felt like I was a leper’; (5) Post-diagnostic mental health: ‘. . . a dark place’; and (6) A process of adaptation: ‘I’m still who I am, I can still do things. . .’ Conclusion: Findings indicate that occupational therapy intervention programmes for people living with early-stage dementia should target difficulties associated with a broad range of activity types, and include components that target mental health and motivational needs. The study adds to existing knowledge about the need to personally tailor interventions to ensure that they meet individual needs, experiences, and circumstances. Findings will inform the development of an occupational therapy intervention programme theory (theory of change) for early-stage dementia.

Improving Pain mAnagement for childreN and young people attendeD by Ambulance (PANDA): protocol for a realist review.

Background Each year in England, 450,000 children and young people (CYP) under 18 years of age are transported by ambulance to emergency departments. Approximately 20% of these suffer acute pain caused by illness or injury. Pain is a highly complex sensory and emotional experience. The intersection between acute pain, unwell CYP and the unpredictable pre-hospital environment is convoluted. Studies have shown that prehospital pain management in CYP is poor, with 61% of those suffering acute pain not achieving effective pain relief (abolition or reduction of pain score by 2 or more out of 10) when attended by ambulance. Consequences of poor acute pain management include altered pain perception, post-traumatic stress disorder and the development of chronic pain. This realist review will aim to understand how ambulance clinicians can provide improved prehospital acute pain management for CYP. Methods A realist review will be conducted in accordance with the Realist And Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) guidance. A five-stage approach will be adopted; 1) Developing an Initial Programme Theory (IPT) – develop an IPT with key stakeholder input and evidence from informal searching; 2) Searching and screening – conduct a thorough search of relevant research databases and grey literature sources and perform screening in duplicate; 3) Document selection – assess documents for relevance and rigour in duplicate; 4) Extracting and organising data – code relevant data into conceptual “buckets” using qualitative data analysis software; and 5) Synthesis and Programme Theory (PT) refinement – utilise a realist logic of analysis to generate context-mechanism-outcome configurations (CMOCs) within and across conceptual “buckets”, test and refine the IPT into a realist PT. Conclusion The realist PT will enhance our understanding of what works best to improve acute prehospital pain management in CYP, which will then be tested and refined within a realist evaluation. Registration PROSPERO Registration: CRD42024505978

Building a programme theory of a specialist paediatric palliative and hospice care programme: development process and methodological reflection

BackgroundPaediatric palliative and hospice care aims to improve the quality of life of children with life-limiting and life-threatening conditions and their families. The number of these patients has risen significantly in recent years, resulting in an increased need for palliative care for this population. Although the need for paediatric palliative and hospice care is growing, meaningful outcome evaluation to demonstrate its effectiveness as a complex healthcare intervention is in its early stages. For complex interventions (programmes), theory-based evaluations have grown in prominence in recent years. They seek to understand how and why an intervention works by uncovering its underlying mechanisms by means of programme theory. To support both outcome evaluation in paediatric palliative care and a reflective practice of programme theorizing, we aimed to describe the construction of a programme theory for a specialist paediatric palliative and hospice care programme in Austria and to offer a reflective account of its development process.MethodsWe drew on a combination of theory-based evaluation frameworks to construct a programme theory consisting of an action and a change component. Through multiple iterations, incorporating different stakeholders’ perspectives and drawing on different sources of knowledge and theory, we theorized how and why the programme likely achieves its intended outcomes.ResultsThe programme theory outlines the proposed chains of events, causal mechanisms and outcomes of a specialist paediatric palliative and hospice care programme for children and families in several areas corresponding to its main conceptual tenets. Through a range of activities and interventions, the programme triggers coping and adaptation mechanisms that ultimately contribute to family and child wellbeing in physical, psychological, social, and spiritual dimensions. Established trust and partnership between children/families and healthcare professionals as well as a person-centered and family-centered approach were identified as enabling factors.ConclusionsOur findings provide insights into how a specialized paediatric palliative and hospice care programme works to achieve its intended outcomes for children and families. This helps demonstrate its impact, contributing to meaningful outcome evaluation and service improvement.

A generic logic model for physical activity interventions for the cardiac population using intervention mapping

Abstract Introduction Regular physical activity is important in the secondary prevention of cardiovascular disease. But many cardiac patients have difficulty establishing lifelong physical activity habits, even after completion of an exercise-based cardiac rehabilitation programme. There is a need for effective interventions to support cardiac patients' physical activity. Such interventions are often complex behaviour change interventions whose design should be grounded in programme theory, i.e., a description of how the intervention is expected to lead to its effects and under what conditions. A logic model is often used to communicate programme theory [1]. Purpose The purpose of this work was to describe a generic logic model for behaviour change interventions to increase and maintain physical activity among patients who have had an acute cardiac event. Methods We applied the Intervention Mapping approach [2] to develop a generic logic model that is both data- and theory-driven, i.e. informed by research evidence and behaviour change theory. The at-risk behaviour for the individual cardiac patient was defined as "insufficient independent long-term maintenance of heart-healthy physical activity", compounded by the environmental factor "lack of support provision for long-term independent physical activity" from the healthcare providers and people in the patient’s interpersonal environment. We defined performance objectives by asking the questions: "What do people who had an acute cardiac event need to do to increase and maintain their heart-healthy physical activity?" and "What do the healthcare providers and people in the patient’s interpersonal environment need to do to encourage and support the patient in being physically active?" The performance objectives specify what actions are required of the individuals targeted in the intervention. We selected determinants corresponding to performance objectives based on empirical evidence from systematic reviews and based on behaviour change theory such as the Reasoned Action Approach (RAA) and the Health Action Process Approach (HAPA). Results Central elements of the logic model are presented in table 1. The logic model includes 18 performance objectives and 13 determinants, supported by empirical evidence from 40 scientific publications. Conclusion The generic logic model serves as a collection of current knowledge regarding increasing and maintaining physical activity among the cardiac population and can be used for a number of purposes: as a foundation for developing new interventions; as a blueprint against which to compare and/or solidify the programme theory of existing interventions; as a conceptual framework for designing evaluations of interventions; as a current evidence map from which to identify research gaps; and as a point of reference for reflecting on one’s own health behaviour.Table 1.Elements of the logic model.

A realist evaluation protocol: assessing the effectiveness of a rapid response team model for mental state deterioration in acute hospitals.

Mental state deterioration poses significant challenges in healthcare, impacting patients and providers. Symptoms like confusion and agitation can lead to prolonged hospital stays, increased costs, and the use of restrictive interventions. Despite its prevalence, there's a lack of consensus on effective practices for managing mental state deterioration in acute hospital settings. To address this gap, a rapid response team model has been proposed as a potential intervention, aiming to provide early identification and targeted interventions. Based on realist evaluation steps, first, initial program theories are formulated to understand the logic behind the intervention. Second, literature synthesis identifies empirical evidence on contexts, mechanisms, and outcomes elements, refining initial theories. During the third step, data will be collected using qualitative methods such as field observations and interviews, as well as quantitative methods such as surveys of the staff, audits of electronic medical records, and analysis of incident records of mental state deterioration. Analysing this data informs configurations of contexts, mechanisms, and outcomes. In the fifth step, the configurations are synthesised, presenting refined, evidence-informed program theories. This study addresses the knowledge gap by evaluating the rapid response model's effectiveness in managing mental state deterioration in acute hospital settings. Realist principles guide the exploration of causal mechanisms and their interaction with specific implementation contexts. The objective is to identify what works, for whom, and under what circumstances, aiming to manage deterioration, reduce restrictive interventions, and enhance the experience for patients and staff by implementing a proactive model of care. The findings contribute to evidence-based approaches for managing mental state deterioration in hospital settings, informing policy and practice in this crucial area of healthcare.

An urgent call to center AsianCrit in Chinese/English dual language bilingual education programs

ABSTRACT In recent years, neoliberal interests in U.S. Chinese/English dual language bilingual education (DLBE) programs have emphasized white, English-speakers’ use of Mandarin for economic and political gains. Such interests reify white supremacy and contribute to the erasure of Chinese and Chinese American voices, histories, and cultures in curriculum and instruction. While early literature on Chinese DLBE contexts examined program success based on students’ academic achievement and biliteracy development, there has been limited attention to cultivating critical consciousness to resist the commodification of language and multiculturalism for capitalist enterprise. Therefore, we propose a cohesive programmatic framework informed by Asian Critical Race Theory (AsianCrit) for Chinese DLBE programs to cultivate critical consciousness as a foundational educational goal. In this conceptual paper, we apply the seven tenets of AsianCrit to U.S. Chinese DLBE contexts to reimagine a community-based, historically-situated, and equity-oriented educational space. We hope this proposal will inform efforts toward just and innovative Chinese DLBE pedagogies and inspire new lines of critical research in the field of bilingual education.

Exploring how and why a sports-based multi-component intervention works for disengaged students: a longitudinal realist evaluation

ABSTRACT School dropout is associated with numerous detrimental consequences including prolonged unemployment, poverty, a wide range of psychological and physical health problems, and premature mortality. As such, designing and implementing interventions to prevent school dropout and ensure successful school completion is crucial. The purpose of the current study was to conduct a longitudinal realist evaluation to understand how, and under which circumstances, a multi-component intervention delivered through the charitable foundation of a professional sports team may impact the developmental outcomes of disengaged students. The intervention comprised one-to-one mentoring, classroom-based learning, sport and physical activity. Participant observations and fifty-two interviews were conducted with teachers and students over a ten-month period to form context-mechanism-outcome configurations (CMOCs) and to refine initial programme theories. The CMOCs developed highlighted the importance of students developing healthy conflict resolution skills and emotional regulation strategies, the potential of sporting content to re-ignite interest in academic learning, the powerful effects of deviant peer contagion, the synergistic impact of a multi-component intervention, and the role of pre-existing and ongoing contextual factors in determining whether interventions can create sustainable and lasting desirable outcomes among students. The findings provide practical recommendations for future sport-framed intervention design, implementation, and evaluation.

The effect of the Watson model-based psycho-educational intervention on preventing postpartum depression.

Psycho-education application is effective in reducing the risk of postpartum depression (PPD) and increasing the level of social support. The quality of care increases with the implementation of Watson's Theory of Human Caring Model (WTHCM)-based care programs to reduce the risk of PPD. This study aimed to evaluate the impact of a psycho-educational intervention based on the Watson model on pregnant women in preventing PPD. Additionally, the effect of the psycho-educational intervention on women's perceptions of social support in relation to PPD was evaluated. A randomized-controlled pretest-posttest control group intervention study design was used. The sample consisted of 91 women (intervention:45, control:46) in their 20th to 32nd gestational week. While all women received routine care at the family health centre the intervention group was additionally applied a psycho-educational intervention based on the WTHCM. Chi-square and t-test analysis methods were performed to determine the homogeneity of the intervention and control groups. The t-test method was used to compare group scores. Multiple regression analysis was employed to compare multiple variables. Following the psycho-educational intervention, the total Edinburgh Postpartum Depression Scale of the intervention group was found significantly lower than that of the control group, but the total and friend subscale scores on the Multidimensional Scale of Perceived Social Support (MSPSS) were higher (p < 0.05). The regression analysis results indicate that friend and family support, which are sub-dimensions of the MSPSS, exhibited a significant decrease in both groups. Furthermore, this decline had a greater impact on reducing the PPD level in the intervention group compared to the control group. It was found that while the support of the significant other sub-dimension reduced the PPD level in the intervention group, it did not make a significant difference in the control group. The Watson's Theory of Human Caring Model-based psycho-educational intervention program decreased women's risk of PPD and increased their social support levels. It is recommended to use approaches that include psycho-educational intervention in postpartum midwifery care.

The interplay between patients and healthcare professionals in a cross-sectoral setting in connection with the treatment and care of patients with diabetic foot ulcers: a realistic evaluation

BackgroundDiabetes-related lower extremity complications such as diabetic foot ulcer (DFU) are a global disability burden. Treatment and care for patients with DFU call for a multisectoral approach that incorporates interdisciplinary care pathways. We aimed to explore the interplay between patients with DFU and healthcare professionals in cross-sectoral settings that address treatment and care and to determine “what works, for whom, and under what circumstances”.MethodThe study was designed as a realistic evaluation. The data were generated from September 2022 to March 2023 and drew upon approximately 60 h of participant observation of 14 patients during the treatment and care of DFUs in their homes (primary care) and/or at outpatient clinics (wound specialist clinics in a hospital setting) in a Danish cross-sectoral setting. The Standards for Reporting Qualitative Research (SRQR) were applied in this study.ResultsWe identified three illuminating themes that described the interplay between patients with DFU and related healthcare professionals representing both primary and secondary health care systems: (1) humour is a relationship-enhancing element between nurses and patients; (2) support from patients’ coping strategies promotes patient-centeredness and collaboration; and (3) patients and professionals occupy unnegotiated identity roles.ConclusionOur study led to a refined programme theory developed through the realistic evaluation process that allows us to propose an answer to the problem of “what works, for whom, and under what circumstances”. The interplay between patients with DFU and healthcare professionals in a cross-sectoral setting for treatment and care is characterised by the use of humour as a relation-enhancing element and by improving support for patient coping strategies, which encourages healthcare professionals to promote health literacy. Future research should examine strategies for negotiating identity roles between patients with DFU and healthcare professionals to enhance collaboration, patient health literacy, and health promotion in cross-sectoral healthcare settings.

Health technology assessment implementation in WHO South-East Asia Region: a realist review protocol.

A robust Health Technology Assessment (HTA) framework is crucial to address the rising burden of healthcare costs and to inform decision-making to promote high-quality health systems. This research aims to describe the HTA methods and mechanisms for the successful implementation of HTA in the WHO South-East Asia region, and contextualize the synthesized evidence relevant to Indian settings. Realist review involves developing a program theory by conducting a systematic search strategy, screening, study selection, data extraction, and data synthesis. A systematic search for literature will be conducted on PubMed (NCBI), EMBASE (Elsevier), Scopus (Elsevier), Web of Science (Clarivate), and ProQuest Central for identifying the methods used for HTA of health technology interventions. Stakeholder consultations will be conducted to develop a program theory following the Context-Mechanism-Outcome configurations (CMOcs) framework. Searches for primary evidence will be conducted iteratively. Data will be extracted and tested against the programme theory. The proposed realist review will be reported as per the Realist and MEta-narrative Evidence Syntheses: Evolving Standards [RAMESES II] guidelines. To our knowledge, there has been no comprehensive review conducted to understand the mechanisms of HTA methods in the WHO South-East Asia region. The findings from the realist review will help us understand the mechanisms through which the HTA could work in WHO South-East Asian countries. We will then contextualize the findings obtained from evidence to Indian settings, based on program theory development through stakeholder consultation. A framework will be developed that can be used by policymakers/HTA experts in India for effective implementation of the same.

Using Palliative Care Needs Rounds in the UK for care home staff and residents: an implementation science study.

Care home residents often lack access to end-of-life care from specialist palliative care providers. Palliative Care Needs Rounds, developed and tested in Australia, is a novel approach to addressing this. To co-design and implement a scalable UK model of Needs Rounds. A pragmatic implementation study using the integrated Promoting Action on Research Implementation in Health Services framework. Implementation was conducted in six case study sites (England, n = 4, and Scotland, n = 2) encompassing specialist palliative care service working with three to six care homes each. Phase 1: interviews (n = 28 care home staff, specialist palliative care staff, relatives, primary care, acute care and allied health practitioners) and four workshops (n = 43 care home staff, clinicians and managers from specialist palliative care teams and patient and public involvement and engagement representatives). Phase 2: interviews (n = 58 care home and specialist palliative care staff); family questionnaire (n = 13 relatives); staff questionnaire (n = 171 care home staff); quality of death/dying questionnaire (n = 81); patient and public involvement and engagement evaluation interviews (n = 11); fidelity assessment (n = 14 Needs Rounds recordings). (1) Monthly hour-long discussions of residents' physical, psychosocial and spiritual needs, alongside case-based learning, (2) clinical work and (3) relative/multidisciplinary team meetings. A programme theory describing what works for whom under what circumstances with UK Needs Rounds. Secondary outcomes focus on health service use and cost effectiveness, quality of death and dying, care home staff confidence and capability, and the use of patient and public involvement and engagement. Semistructured interviews and workshops with key stakeholders from the six sites; capability of adopting a palliative approach, quality of death and dying index, and Canadian Health Care Evaluation Project Lite questionnaires; recordings of Needs Rounds; care home data on resident demographics/health service use; assessments and interventions triggered by Needs Rounds; semistructured interviews with academic and patient and public involvement and engagement members. The programme theory: while care home staff experience workforce challenges such as high turnover, variable skills and confidence, Needs Rounds can provide care home and specialist palliative care staff the opportunity to collaborate during a protected time, to plan for residents' last months of life. Needs Rounds build care home staff confidence and can strengthen relationships and trust, while harnessing services' complementary expertise. Needs Rounds strengthen understandings of dying, symptom management, advance/anticipatory care planning and communication. This can improve resident care, enabling residents to be cared for and die in their preferred place, and may benefit relatives by increasing their confidence in care quality. COVID-19 restricted intervention and data collection. Due to an insufficient sample size, it was not possible to conduct a cost-benefit analysis of Needs Rounds or calculate the treatment effect or family perceptions of care. Our work suggests that Needs Rounds can improve the quality of life and death for care home residents, by enhancing staff skills and confidence, including symptom management, communications with general practitioners and relatives, and strengthen relationships between care home and specialist palliative care staff. Conduct analysis of costs-benefits and treatment effects. Engagement with commissioners and policy-makers could examine integration of Needs Rounds into care homes and primary care across the UK to ensure equitable access to specialist care. This study is registered as ISRCTN15863801. This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR128799) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 19. See the NIHR Funding and Awards website for further award information.

How does mentoring occupational therapists improve intervention fidelity in a randomised controlled trial? A realist evaluation

BackgroundIntegrating complex interventions within healthcare settings can be challenging. Mentoring can be embedded within a randomised controlled trial (RCT) to upskill and support those delivering the intervention. This study aimed to understand, from a realist perspective, how mentoring worked to support implementation fidelity for occupational therapists (OTs) delivering a vocational rehabilitation (VR) intervention within the context of an RCT.MethodsA realist evaluation using secondary data (emails, mentoring record forms, interviews) collected as part of an RCT. Three researchers coded the data following content analysis, focused on refining or refuting an initial programme theory by exploring the interactions between context, mechanisms, and outcomes. The research team met to further refine the programme theories.ResultsData from 584 emails, 184 mentoring record forms, and 25 interviews were analysed following a realist approach. We developed a programme theory consisting of two contexts (trial set-up, ongoing mentoring), nine mechanisms (collective understanding, monitoring, timely support, positive reinforcement, reflective practice, support data completeness, facilitation strategy, shared learning experience, management of research and clinical duties), and three outcomes (improved confidence, improved fidelity, reduced contamination).ConclusionsOffering mentoring support to OTs delivering a VR intervention as part of an RCT improves intervention fidelity and reduces the risk of contamination. It improves OTs’ understanding of the differences between their clinical and research roles and increases their confidence and competence in trial paperwork completion and identification of potential contamination issues.

A Smart Approach For Budget Deficits PredictionUnder Economic Shocks

Historically, the main behavior of fiscal policy is to distribute resources, income, and expenditures, which are interconnected functions of economic stability. Recently, the scope of public sector economics has expanded beyond budgetary components in parallel with the development of public finance. While the budget reached the economic division form of budget items based on program and performance theories, Budget monitoring, and financial risk management are currently challenging, particularly in the face of monetary policy uncertainty. Financial institutions are crucially concerned with the stability of public finance in low-income countries (LICs) as it contributes to improved investor confidence and fiscal decision-making. Hence, economists investigated uncertainty shocks and contributed to managing financial risks with global and energy uncertainty indices. Furthermore, the maturity of digital transformation and artificial intelligence financial applications catalyzed scholars to examine its contributions in the fiscal distress prediction field. Hence, this research aims to integrate artificial intelligence into financial performance analysis to bridge the gap in budget forecasting. The study was aimed at proposing an Economics Division Uncertainty approach (EDUA), which combined (ARIMA) and (LSTM) models for time series analysis of Nuclear Material Authority expenditures over the previous five years divided into quarterly periods, to achieve efficiency in spending. The (ARIMA) model’s (ADF) results showed that uncertainty indicators are highly significant. The best (p-value) in the first and second differences in (ARIMA) models is (0.0001) for petroleum items, (0.0001) for solar price rates, (0.001) for the US exchange rate, and (0.003) for electricity price rates, when compared to (EDU_LSTM). Both models have similar accuracy rates, with the best being (EDU_ARIMA) (solar price 97%, USD exchange rate 84%). The second study proposed a composite model of four machine-learning tools to enhance financial performance during financial distress. The study collected (12) indicators from general financial literature and corporate studies, utilizing the (XGBOOST, Random Forest, KNN, and Naïve Bayes) models. Comparing the accuracy results for each model presented different accuracy results in the deep learning models over five years of data. The best accuracy score was for Random Forest at (69%), XGBOOT at (68%), and KNN at (68%). We recommended explainable AI as future research to interpret the budget deficit during the fiscal year period. Keywords: Economic Shocks, Uncertainty, Budget Reliability, Financial Distress Prediction, Artificial Intelligence.

Realist process evaluation of the knowledge translation programme of a patient‐oriented research network

AbstractRationaleThe Knowledge Translation (KT) Programme of a pan‐Canadian strategic patient‐oriented research network focused on brain‐based developmental disabilities aimed to mobilize knowledge relevant to the network members. The programme also promotes and studies integrated Knowledge Translation (iKT) approaches involving different interested parties, such as researchers, patient‐partners and decision‐makers, in all parts of the knowledge creation process.Aims and ObjectivesThe objective of this study is to advance research programme evaluation methods through a realist evaluation of the process of implementing iKT activities.MethodsRealist process evaluation included: (1) development of initial programme theories (using the partnership synergy theory); (2) data collection and analysis; (3) synthesis and refinement of theories through engagement with literature; and (4) presentation of findings in context‐mechanism‐outcome (C‐M‐O) configurations. A range of project documentation records were reviewed for analysis, and three co‐leads, a programme coordinator, and a senior research associate were consulted to contextualize the implementation process of relevant KT activities.ResultsBased on the developed C‐M‐O configurations, we identified five key mechanisms of generating synergy in the iKT processes: (1) Visible shared leadership that embodies what iKT looks like; (2) Researchers' readiness for iKT; (3) Adaptation and flexible allocation of resources to emerging needs; (4) Power sharing to create practical and creative knowledge; and (5) Collective voice for potential transformative impacts at the policy level.ConclusionsThe current realist evaluation demonstrated how partnerships between researchers, patient‐partners and other interested parties can synergistically generate new ways of thinking among all interested parties, actionable strategies to integrate users in research, and solutions to disseminate knowledge. In particular, we identified a pivotal role for patient‐partners to act as equal decision‐maker helps building and maintaining partnerships and consolidating KT strategies.