Realist And Meta-narrative Evidence Syntheses : Evolving Standards Research Articles

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.

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

Integrated care system leadership: a rapid realist review

PurposeGiven the complex nature of integrated care systems (ICSs), the geographical spread and the large number of organisations involved in partnership delivery, the importance of leadership cannot be overstated. This paper aims to present novel findings from a rapid realist review of ICS leadership in England. The overall review question was: how does leadership in ICSs work, for whom and in what circumstances?Design/methodology/approachDevelopment of initial programme theories and associated context–mechanism–outcome configurations (CMOCs) were supported by the theory-gleaning activities of a review of ICS strategies and guidance documents, a scoping review of the literature and interviews with key informants. A refined programme theory was then developed by testing these CMOCs against empirical data published in academic literature. Following screening and testing, six CMOCs were extracted from 18 documents. The study design, conduct and reporting were informed by the Realist And Metanarrative Evidence Syntheses: Evolving Standards (RAMESES) training materials (Wong et al., 2013).FindingsThe review informed four programme theories explaining that leadership in ICSs works when ICS leaders hold themselves and others to account for improving population health, a sense of purpose is fostered through a clear vision, partners across the system are engaged in problem ownership and relationships are built at all levels of the system.Research limitations/implicationsDespite being a rigorous and comprehensive investigation, stakeholder input was limited to one ICS, potentially restricting insights from varied geographical contexts. In addition, the recent establishment of ICSs meant limited literature availability, with few empirical studies conducted. Although this emphasises the importance and originality of the research, this scarcity posed challenges in extracting and applying certain programme theory elements, particularly context.Originality/valueThis review will be of relevance to academics and health-care leaders within ICSs in England, offering critical insights into ICS leadership, integrating diverse evidence to develop new evidence-based recommendations, filling a gap in the current literature and informing leadership practice and health-care systems.

Lost in translation: how can education about dementia be effectively integrated into medical school contexts? A realist synthesis

ObjectivesThe prevalence of dementia in both community and hospital settings requires a clinical workforce that is skilled in diagnosis and management of the condition to competently care for patients. Though...

Understanding strategies that foster nurses to act as clinical leaders in hospitals: A realist review.

To identify strategies that develop clinical nursing leadership competencies among staff nurses, and to explain the contextual elements and mechanisms that underpin the development of clinical nursing leadership competencies. Realist review according to the Realist and Meta-narrative Evidence Syntheses-Evolving Standards (RAMESES). PubMed, Embase, CINAHL, Web of Science, Wiley Online Library, PsycInfo and ProQuest were searched from January 2000 until October 2022. Three iterative phases: (1) development of initial programme theory, (2) structured searches for relevant published and grey literature and (3) data synthesis and interpretation by researchers and theory triangulation, and discussions within the research group. Multiple context-mechanism-outcome configurations were extracted from 10 reports that explain how, under what circumstances and why strategies can facilitate (or discourage) staff nurses to act as clinical leaders. Reports were both quantitative and qualitative in design, originating from English-speaking countries only. A logic model was developed and suggests four contexts and five mechanisms underlying the development of clinical nursing leadership. Growth in clinical nursing leadership was mainly experienced through experiential learning, which was enhanced by a supportive relationship with a coach or mentor, the use of reflective practices and modelling from other leaders. Furthermore, a supportive work environment triggers ownership, confidence and motivation, and thereby growth in clinical nursing leadership competencies. Fostering competencies for clinical leadership among staff nurses requires multifaceted strategies. Strategies are successful if, and only if, they combine learning by doing, by knowing and by observing, and establish a responsive work environment. Hospital policy should ensure that staff nurses have access to reciprocal relationships with role models or a coach. In order to grow as clinical nurse leader, ownership and self-reflection on own leadership behaviour need to be facilitated. Prospero ID CRD42021292290.

How does participatory research work: protocol for a realist synthesis

IntroductionParticipatory research science deals with partnerships underlying research, governance and ownership of research products. It is concerned with relationships behind research objectives and methods. Participatory research has gained significant traction...

Improving Peer Online Forums (iPOF): protocol for a realist evaluation of peer online mental health forums to inform practice and policy

IntroductionPeer online mental health forums are commonly used and offer accessible support. Positive and negative impacts have been reported by forum members and moderators, but it is unclear why these...

Health visiting in the UK in light of the COVID-19 pandemic experience (RReHOPE): a realist review protocol

IntroductionHealth visiting services, providing support to under 5s and their families, are organised and delivered in very different ways in different parts of the UK. While there has been attention...

Indicators for Modernising the LIS Internship: Evidences from a systematic literature review

This systematic literature review was conducted to analyse the existing literature on the internship programme in library and information science (LIS) education. The review was guided by the RAMESES (Realist and Meta-Narrative Evidence Syntheses: Evolving Standards) method. The data source was Scopus, Web of Science and Google Scholar. In addition to the three main phases of the review process, mainly identification, screening, and eligibility, data abstraction and analysis are also reported. Findings reveal that studies on LIS internship have focused on satisfaction, educational benefits, educational setting, programme design and roles of the stakeholders involved in internship programmes. Modernising the LIS Internship programme requires a focus on the design of the programme structure with an emphasis on the learning outcomes relating to career readiness. Collaborative learning, service-learning and personal objectives are found to be beneficial. However, there is also an increasing demand for needs of the stakeholders and not just the student-centred learning. Further works into the assessment of the learning outcomes is recommended by the literature.

Vaccine equity in COVID-19: a meta-narrative review

The topic of inequitable vaccine distribution has been widely discussed by academics, journalists and policy-makers in the context of the COVID-19 pandemic. However, research into perceptions of vaccine equity has...

Why patients in specialist palliative care in-patient settings are at high risk of falls and falls-related harm: A realist synthesis

Background: Falls are the third highest reported safety incident in Specialist Palliative Care in-patient settings and yet specific risk factors connected with falling and associated outcomes in this setting are poorly understood. Aim: To understand the key individualised risk factors leading to falls in specialist in-patient palliative care settings and understand the implications and outcomes for the patients who fall. Design: A realist synthesis of the literature, reported following the Realist And Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) standards. Data sources: An iterative literature search was conducted across three recognised health collections as well as grey literature from policy, practice and other relevant areas. Results: Falls taking place within in-patient specialist palliative care settings can cause significant harm to patients. The risk factors for these patients are multifaceted and often interlinked with underpinning complex realist mechanisms including a history of falls, the age of the person, impact of complex medications, improving functional status and the presence of delirium. Conclusion: In-patients in specialist palliative care settings are at risk of falling and this is multifactorial with complex reasoning mechanisms underpinning the identified risks. There is a significant impact of a fall in this cohort of patients with many sustaining serious harm, delayed discharge and both physical and psychological impacts.

Understanding primary care diagnosis and management of sleep disturbance for people with dementia or mild cognitive impairment: a realist review protocol

IntroductionThe increasingly ageing population is associated with greater numbers of people living with dementia (PLwD) and mild cognitive impairment (MCI). There are an estimated 55 million PLwD and approximately 6%...

A realist review of voluntary actions by the food and beverage industry and implications for public health and policy in low- and middle-income countries.

The increasing availability of unhealthy processed food products is linked to rising rates of non-communicable diseases and obesity in low- and middle-income countries. Voluntary actions (VAs) are often adopted in lieu of regulating the composition, production, marketing and sale of unhealthy commodities, but their effectiveness is unclear. This realist review examines VAs adopted by the food and beverage industry in low- and middle-income countries. We developed a conceptual framework and followed a three-stage search to identify literature and VAs and, adhering to the Realist and Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) guidelines, we produced a synthesized analysis of VAs. VAs, often initiated in response to governments' efforts to introduce regulations, were difficult to evaluate due to vague language and a lack of enforcement mechanisms. The review found no evidence indicating that VAs are effective in safeguarding public health. Yet their implementation has resulted in weaker responses and policy substitution, and so we suggest that VAs have the potential to negatively influence public health and policy. The United Nations should rescind their endorsement of industry involvement and mandatory measures should be favoured over VAs.

Person-centred care in primary care: What works for whom, how and in what circumstances?

This rapid realist review aims to explain how and why person-centred care (PCC) in primary care works (or not) among others for people with low health literacy skills and for people with a diverse ethnic and socioeconomic background, and to construct a middle-range programme theory (PT). Peered reviewed- and non-peer-reviewed literature (Jan 2013-Feb 2021) reporting on PCC in primary care was included. Selection and appraisal of documents were based on relevance and rigour according to the Realist And Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) criteria. Data on context, mechanisms and outcomes (CMO) were extracted. Based on the extracted data, CMO configurations were identified per source publication. Configurations containing all three constructs (CMO) were included in the PT. The middle-range PT demonstrates that healthcare professionals (HCPs) should be trained and equipped with the knowledge and skills to communicate effectively (i.e. in easy-to-understand words, emphatically, checking whether the patient understands everything, listening attentively) tailored to the wishes, needs and possibilities of the patient, which may lead to higher satisfaction. This way the patient will be more involved in the care process and in the shared decision-making process, which may result in improved concordance, and an improved treatment approach. A respectful and empathic attitude of the HCP plays an important role in establishing a strong therapeutic relationship and improved health (system) outcomes. Together with a good accessibility of care for patients, setting up a personalised care plan with all involved parties may positively affect the self-management skills of patients. Good collaboration within the team and between different domains is desirable to ensure good care coordination. The coherence of items related to PCC in primary care should be considered to better understand its effectiveness.

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.

Developing programme theories of leadership for integrated health and social care teams and systems: a realist synthesis

BackgroundAs the organisation of health and social care in England moves rapidly towards greater integration, the resulting systems and teams will require distinctive leadership. However, little is known about how the effective leadership of these teams and systems can be supported and improved. In particular, there is relatively little understanding of how effective leadership across integrated care teams and systems may be enacted, the contexts in which this might take place and the subsequent implications this has on integrated care.ObjectiveThis realist review developed and refined programme theories of leadership of integrated health and social care teams and systems, exploring what works, for whom and in what circumstances.DesignThe review utilised a realist synthesis approach, informed by the Realist And Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) publication standards, to explore existing literature on the leadership of integrated care teams and systems, complemented by ongoing stakeholder consultation. Empirical evidence specifically addressing leadership of integrated teams or services was limited, with only 36 papers included in the review. The evidence collected from these 36 papers was synthesised to identify and build a comprehensive description of the mechanisms of leadership of integrated teams and systems and their associated contexts and outcomes. Consultation with key stakeholders with a range of expertise throughout the process ensured that the review remained grounded in the reality of health and social care delivery and addressed practice and policy challenges.ResultsEvidence was identified for seven potentially important components of leadership in integrated care teams and systems. These were ‘inspiring intent to work together’, ‘creating the conditions to work together’, ‘balancing multiple perspectives’, ‘working with power’, ‘taking a wider view’, ‘a commitment to learning and development’ and ‘clarifying complexity’. No empirical evidence was found for an eighth mechanism, ‘fostering resilience’, although stakeholders felt that this was potentially an important, long-term component of leadership. A key message of the review was that empirical research often focused on the importance of who the leader of an integrated team or service was (i.e. their personality traits and characteristics) rather than what they did (i.e. the specific role that they played in integrated working), although stakeholders considered that a focus on leader personality was not sufficient. Other key messages highlighted the way in which power and influence are used by integrated service leaders and identified the hierarchies between health and social care which complicate the leading of integrated teams and systems.LimitationsEvidence specifically addressing leadership of integrated care teams and systems was limited and lacking in detail, which restricted the degree to which definitive conclusions could be drawn around what works, for whom and in what circumstances.ConclusionsResearch into the leadership of integrated care teams and systems is limited and underdeveloped, with ideas often reverting to existing framings of leadership in which teams and organisations are less complex. In making explicit some of the assumptions about how leaders lead integrated care teams and systems this review has contributed significant new perspectives, offering fresh theoretical grounding that can be built on, developed and tested further.Future workBy making explicit some of the assumptions underlying the leadership of integrated care teams and systems, this review has generated new perspectives that can be built on, developed and tested further.Study registrationThis study is registered as PROSPERO CRD42018119291.FundingThis project was funded by the National Institute for Health Research (NIHR) Health and Social Care Delivery Research programme and will be published in full inHealth and Social Care Delivery Research; Vol. 10, No. 7. See the NIHR Journals Library website for further project information.

Culture and understanding the role of feedback for health professions students: realist synthesis protocol

IntroductionClinical education has moved to a ‘competency-based’ model with an emphasis on workplace-based learning and assessment which, in turn, depends on feedback to be effective. Further, the understanding of feedback...

Preventing Childhood Obesity in Primary Schools: A Realist Review from UK Perspective.

Childhood obesity is a global public health concern. While evidence from a recent comprehensive Cochrane review indicates school-based interventions can prevent obesity, we still do not know how or for whom these work best. We aimed to identify the contextual and mechanistic factors associated with obesity prevention interventions implementable in primary schools. A realist synthesis following the Realist And Meta-narrative Evidence Syntheses–Evolving Standards (RAMESES) guidance was with eligible studies from the 2019 Cochrane review on interventions in primary schools. The initial programme theory was developed through expert consensus and stakeholder input and refined with data from included studies to produce a final programme theory including all of the context-mechanism-outcome configurations. We included 24 studies (71 documents) in our synthesis. We found that baseline standardised body mass index (BMIz) affects intervention mechanisms variably as a contextual factor. Girls, older children and those with higher parental education consistently benefitted more from school-based interventions. The key mechanisms associated with beneficial effect were sufficient intervention dose, environmental modification and the intervention components working together as a whole. Education alone was not associated with favourable outcomes. Future interventions should go beyond education and incorporate a sufficient dose to trigger change in BMIz. Contextual factors deserve consideration when commissioning interventions to avoid widening health inequalities.

Tensions and opportunities in social prescribing. Developing a framework to facilitate its implementation and evaluation in primary care: a realist review.

BackgroundSocial prescribing (SP) involves linking patients in primary care with services provided by the voluntary and community sector (VCS). Despite growing interest within NHS primary care, it remains unclear how and under what circumstances SP might contribute to good practice.AimTo define ‘good’ practice in SP by identifying context-specific enablers and tensions. To contribute to the development of an evidence-based framework for theorising and evaluating SP within primary care.Design & settingRealist review of secondary data from primary care-based SP schemes.MethodAcademic articles and grey literature were searched for qualitative and quantitative evidence following the Realist And Meta-narrative Evidence Syntheses — Evolving Standards (RAMESES). Common SP practices were characterised in three settings (general practice, link workers, and community sector) using archetypes that ranged from best to worst practice.ResultsA total of 140 studies were included for analysis. Resources were identified influencing the type and potential impact of SP practices and four dimensions were outlined in which opportunities for good practice arise: 1) individual characteristics (stakeholder’s buy-in, vocation, and knowledge); 2) interpersonal relations (trustful, bidirectional, informed, supportive, and transparent and convenient interactions within and across sectors); 3) organisational contingencies (the availability of a predisposed practice culture, leadership, training opportunities, supervision, information governance, resource adequacy, accessibility, and continuity of care within organisations); and 4) policy structures (bottom-up and coherent policymaking, stable funding, and suitable monitoring strategies). Findings were synthesised in a multilevel, dynamic, and usable SP framework.ConclusionThe realist review and resulting framework revealed that SP is not inherently advantageous. Specific individual, interpersonal, organisational, and policy resources are needed to ensure SP best practice in primary care.

Realist Evaluation of Autism ServiCe Delivery (RE-ASCeD): which diagnostic pathways work best, for whom and in what context? Protocol for a rapid realist review.

IntroductionThe National Health Service (NHS) Long-Term Plan (2019) acknowledges that children and young people with suspected autism wait too long for diagnostic assessment and sets out to reduce waiting times. However, diagnostic pathways vary with limited evidence on what model works best, for whom and in what circumstances. The National Autism Plan for Children (2003) recommended that assessment should be completed within 13 weeks but referral to diagnosis can take as long as 799 days.This Rapid Realist Review (RRR) is the first work package in a national programme of research: a Realist Evaluation of Autism ServiCe Delivery (RE-ASCeD). We explore how particular approaches may deliver high-quality and timely autism diagnostic services for children with possible autism; high quality is defined as compliant with National Institute for Heath and Care Excellence (2011) guidelines, and timely as a pathway lasting no more than one calendar year, based on previous work.Methods and analysisRRR is a well-established approach to synthesising evidence within a compressed timeframe to identify models of service delivery leading to desired outcomes. RRR works backwards from intended outcomes, identified by NICE guidelines and the NHS England Long-Term Plan. The focus is a clearly defined intervention (the diagnostic pathway), associated with specific outcomes (high quality and timely), within a particular set of parameters (Autism and Child & Adolescent Mental Health services in the UK). Our Expert Stakeholder Group consists of policymakers, content experts and knowledge users with a wide range of experience to supplement, tailor and expedite the process. The RRR is consistent with Realist And Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) and includes identifying the research question, searching for information, quality appraisal, data extraction, synthesising the evidence, validation of findings with experts and dissemination.Ethics and disseminationEthical approval not required. Findings will inform the wider RE-ASCeD evaluation and be reported to NHS England.Trial registration number NCT04422483. This protocol relates to Pre-results.