Den franske kunstneren Eugène Carrière virket i 1800-tallets slutt og har hovedsakelig blitt omtalt og definert som del av den symbolistiske retningen både i hans samtid og i ettertiden. I litteraturen jeg har studert, omhandlende symbolismen og dens virkende aktører,omtales Carrière gjennomgående nokså generelt og mer eller mindre med lignende beskrivelser av hans kunst: Hans bilders motiv utgikk til størst del fra familielivet og moderskapet, inspirert av hans hustru og deres barn på en måte som samtidig kunne koples til drømmene. Fra den tidlige perioden av hans kunstnerskap fantes det i større grad innflytelser fra det naturalistiske maleriet, men hans stil utvikledes deretter til en mer personlig og beveget seg dermed mer vekk fra den direkte avbildningen og mot hva som altså omtales som symbolistisk. Hans teknikk var dog nokså unik i hans fargebruk som var minimert til hovedsakelig brune og gråe toner påført i tynne, synlige penselstrøk, men for øvrig opplevdes hans verk som mindre utfordrende og heller nokså sentimentale, og sees som en mulig grunn til at han til dels har blitt ”bortglemt” gjennom historien, noe Pierre-Louis Mathieus introduksjon til avsnittet om Eugène Carrière i boken The Symbolist Generation kan vise på: ”A fairly neglected artist today, owing perhaps to the repetitive and somewhat old-fashioned sentimentality of his favorite subjects”. Uti fra dette resonnementet kan dermed Carrière oppfattes som en middelmådig, allmenndaglig kunstner i sin tid uten det mest banebrytende kunstnerskap. Er det kun slik man har ønsket å omhandle ham? Gir hans motiv og hans teknikk kun muligheten til denne tolkningen eller finnes det flere muligheter? Dette er hva jeg ønsker å ta rede på i denne uppsatsen. Gjennom inngående billedanalyser av utvalgte verk ønsker jeg å belyse andre aspekter, som genus og hvordan bildene eventuelt kan si noe om de sosiale omstendigheter i tiden, men videre også gjennom vår persepsjon utforske bildenes innhold avskilt fra den øvrige virkelighet og se hvilket inntrykk de kan gi av Carrière som del av såkalte fin de siecle og den pågående utvikling i modernismens retning mot det autonome maleri. Jeg har valgt å ta for meg tre verk som hver og ett vil bli beskrevet, analysert formalistisk og gitt mulige tolkninger: Alphonse Daudet et sa fille 1891 (Musée d’Orsay), Aprés le bain 1887 (Musée d’Orsay) og Le Théatre de Belleville 1886-1895 (Le Musée Rodin). Jeg mener dette er tre verk som på ulike måter kan vise på sider av Carrières kunst der fokuset kan legges et annet sted enn kun hos hans bruk av sin egen familie som modeller, noe som til dels ellers kan se ut til å ha vært en gjennomgående generell oppfatning.

Background: Despite the increasing popularity of using social media to disseminate and translate knowledge, there remains a lack of theoretical understanding of how social media can work for healthcare providers’ knowledge use. The purpose of this thesis was to understand how and under what circumstances social media supports healthcare providers’ use of knowledge in clinical practice. Methods: Drawing on the tenets of scientific realism and the context (C) + mechanism (M) = outcome (O) (CMO) heuristic, a three-phase multi-method study was conducted to build a progressive theoretical understanding of how social media supports healthcare providers’ use of knowledge: 1) theory gleaning by a narrative review of five social media initiatives, five theories, and 58 empirical studies; 2) theory refining by a realist review of 32 articles; and 3) theory consolidation by a realist-informed qualitative study with 11 participants. Results: The Social Media for ImpLementing Evidence (SMILE) framework was developed in the theory gleaning phase. In the theory refining phase, two causal explanations were identified: 1) the rationality-driven approach that primarily uses open social media platforms (eight CMOs), and 2) the relationality-driven approach that primarily uses closed social media platforms (six CMOs). In the theory consolidation phase, the program theory developed for open social media platforms from the realist review was refined to ten CMOs, of which four confirmed the original CMOs, four refined the original CMOs, and two were new CMO propositions. The key mechanisms included content developers’ capabilities and capacities, along with healthcare providers’ increased attention; fulfillment of information needs; access to social influence and support; perception of message value and implementability; behaviour capabilities, self-efficacy, intention, and awareness; and ability to exercise professional autonomy. Conclusions: Through a three-phase realist theory development process, a theoretical understanding of how social media supports healthcare providers’ knowledge use in clinical practice was built. Future research is necessary to further develop this framework and investigate the synergistic effects of the rationality and relationality-driven approaches.

No description available.

Yes / Technology has the potential to provide support for self-management to people with congestive heart failure (CHF). This paper describes the results of a realist evaluation of the SMART Personalised Self-Management System (PSMS) for CHF. Methods The PSMS was used, at home, by seven people with CHF. Data describing system usage and usability as well as questionnaire and interview data were evaluated in terms of the context, mechanism and outcome hypotheses (CMOs) integral to realist evaluation. Results The CHF PSMS improved heart failure related knowledge in those with low levels of knowledge at baseline, through providing information and quizzes. Furthermore, participants perceived the self-regulatory aspects of the CHF PSMS as being useful in encouraging daily walking. The CMOs were revised to describe the context of use, and how this influences both the mechanisms and the outcomes. Conclusions Participants with CHF engaged with the PSMS despite some technological problems. Some positive effects on knowledge were observed as well as the potential to assist with changing physical activity behaviour. Knowledge of CHF and physical activity behaviour change are important self-management targets for CHF, and this study provides evidence to direct the further development of a technology to support these targets.

Yes / To capture stakeholders’ theories concerning how and in what contexts robot-assisted surgery becomes integrated into routine practice. A literature review provided tentative theories that were revised through a realist interview study. Literature-based theories were presented to the interviewees, who were asked to describe to what extent and in what ways those theories reflected their experience. Analysis focused on identifying mechanisms through which robot-assisted surgery becomes integrated into practice and contexts in which those mechanisms are triggered. Nine hospitals in England where robot-assisted surgery is used for colorectal operations. Forty-four theatre staff with experience of robot-assisted colorectal surgery, including surgeons, surgical trainees, theatre nurses, operating department practitioners and anaesthetists. Interviewees emphasised the importance of support from hospital management, team leaders and surgical colleagues. Training together as a team was seen as beneficial, increasing trust in each other’s knowledge and supporting team bonding, in turn leading to improved teamwork. When first introducing robot-assisted surgery, it is beneficial to have a handpicked dedicated robotic team who are able to quickly gain experience and confidence. A suitably sized operating theatre can reduce operation duration and the risk of de-sterilisation. Motivation among team members to persist with robot-assisted surgery can be achieved without involvement in the initial decision to purchase a robot, but training that enables team members to feel confident as they take on the new tasks is essential. We captured accounts of how robot-assisted surgery has been introduced into a range of hospitals. Using a realist approach, we were also able to capture perceptions of the factors that support and constrain the integration of robot-assisted surgery into routine practice. We have translated these into recommendations that can inform future implementations of robot-assisted surgery.

Yes / The implementation of robot-assisted surgery (RAS) can be challenging, with reports of surgical robots being underused. This raises questions about differences compared with open and laparoscopic surgery and how best to integrate RAS into practice. Objectives: To (1) contribute to reporting of the ROLARR (RObotic versus LAparoscopic Resection for Rectal cancer) trial, by investigating how variations in the implementation of RAS and the context impact outcomes; (2) produce guidance on factors likely to facilitate successful implementation; (3) produce guidance on how to ensure effective teamwork; and (4) provide data to inform the development of tools for RAS. Design: Realist process evaluation alongside ROLARR. Phase 1 – a literature review identified theories concerning how RAS becomes embedded into practice and impacts on teamwork and decision-making. These were refined through interviews across nine NHS trusts with theatre teams. Phase 2 – a multisite case study was conducted across four trusts to test the theories. Data were collected using observation, video recording, interviews and questionnaires. Phase 3 – interviews were conducted in other surgical disciplines to assess the generalisability of the findings. Findings: The introduction of RAS is surgeon led but dependent on support at multiple levels. There is significant variation in the training provided to theatre teams. Contextual factors supporting the integration of RAS include the provision of whole-team training, the presence of handpicked dedicated teams and the availability of suitably sized operating theatres. RAS introduces challenges for teamwork that can impact operation duration, but, over time, teams develop strategies to overcome these challenges. Working with an experienced assistant supports teamwork, but experience of the procedure is insufficient for competence in RAS and experienced scrub practitioners are important in supporting inexperienced assistants. RAS can result in reduced distraction and increased concentration for the surgeon when he or she is supported by an experienced assistant or scrub practitioner. Conclusions: Our research suggests a need to pay greater attention to the training and skill mix of the team. To support effective teamwork, our research suggests that it is beneficial for surgeons to (1) encourage the team to communicate actions and concerns; (2) alert the attention of the assistant before issuing a request; and (3) acknowledge the scrub practitioner’s role in supporting inexperienced assistants. It is beneficial for the team to provide oral responses to the surgeon’s requests. Limitations: This study started after the trial, limiting impact on analysis of the trial. The small number of operations observed may mean that less frequent impacts of RAS were missed. Future work: Future research should include (1) exploring the transferability of guidance for effective teamwork to other surgical domains in which technology leads to the physical or perceptual separation of surgeon and team; (2) exploring the benefits and challenges of including realist methods in feasibility and pilot studies; (3) assessing the feasibility of using routine data to understand the impact of RAS on rare end points associated with patient safety; (4) developing and evaluating methods for whole-team training; and (5) evaluating the impact of different physical configurations of the robotic console and team members on teamwork. / National Inst for Health Research (NIHR)

Yes / Falls are the most common safety incident reported by acute hospitals. In England national guidance recommends delivery of a multifactorial falls risk assessment (MFRA) and interventions tailored to address individual falls risk factors. However, there is variation in how these practices are implemented. This study aimed to explore the variation by examining what supports or constrains delivery of MFRAs and tailored interventions in acute hospitals. A realist review of literature was conducted with searches completed in three stages: (1) to construct hypotheses in the form of Context, Mechanism, Outcome configurations (CMOc) about how MFRAs and interventions are delivered, (2) to scope the breadth and depth of evidence available in Embase to test the CMOcs, and (3) following prioritisation of CMOcs, to refine search strategies for use in multiple databases. Citations were managed in EndNote; titles, s, and full texts were screened, with 10% independently screened by two reviewers. Two CMOcs were prioritised for testing labelled: Facilitation via MFRA tools, and Patient Participation in interventions. Analysis indicated that MFRA tools can prompt action, but the number and type of falls risk factors included in tools differ across organisations leading to variation in practice. Furthermore, the extent to which tools work as prompts is influenced by complex ward conditions such as changes in patient condition, bed swaps, and availability of falls prevention interventions. Patient participation in falls prevention interventions is more likely where patient directed messaging takes individual circumstances into account, e.g., not wanting to disturb nurses by using the call bell. However, interactions that elicit individual circumstances can be resource intensive and patients with cognitive impairment may not be able to participate despite appropriately directed messaging. Organisations should consider how tools can be developed in ways that better support consistent and comprehensive identification of patients' individual falls risk factors and the complex ward conditions that can disrupt how tools work as facilitators. Ward staff should be supported to deliver patient directed messaging that is informed by their individual circumstances to encourage participation in falls prevention interventions, where appropriate. PROSPERO: CRD42020184458. / This research is funded by the National Institute for Health Research (NIHR) Health and Social Care Delivery Research (HSDR) Programme (project number NIHR129488).

Yes / There is increasing interest in using artificial intelligence (AI) in pathology to improve accuracy and efficiency. Studies of clinicians' perceptions of AI have found only moderate acceptability, suggesting further research is needed regarding integration into clinical practice. This study aimed to explore stakeholders' theories concerning how and in what contexts AI is likely to become integrated into pathology. Materials and Methods: A literature review provided tentative theories that were revised through a realist interview study with 20 pathologists and 5 pathology trainees. Questions sought to elicit whether, and in what ways, the tentative theories fitted with interviewees' perceptions and experiences. Analysis focused on identifying the contextual factors that may support or constrain uptake of AI in pathology. Results: Interviews highlighted the importance of trust in AI, with interviewees emphasizing evaluation and the opportunity for pathologists to become familiar with AI as means for establishing trust. Interviewees expressed a desire to be involved in design and implementation of AI tools, to ensure such tools address pressing needs, but needs vary by subspecialty. Workflow integration is desired but whether AI tools should work automatically will vary according to the task and the context. Conclusions: It must not be assumed that AI tools that provide benefit in one subspecialty will provide benefit in others. Pathologists should be involved in the decision to introduce AI, with opportunity to assess strengths and weaknesses. Further research is needed concerning the evidence required to satisfy pathologists regarding the benefits of AI. / This work was undertaken as part of the National Pathology Imaging Co-operative. National Pathology Imaging Co-operative, NPIC (Project no. 104687) is supported by a £50m investment from the Data to Early Diagnosis and Precision Medicine strand of the government’s Industrial Strategy Challenge Fund, managed and delivered by UK Research and Innovation (UKRI).

Yes / National audits aim to reduce variations in quality by stimulating quality improvement. However, varying provider engagement with audit data means that this is not being realised. The aim of the study was to develop and evaluate a quality dashboard (i.e. QualDash) to support clinical teams’ and managers’ use of national audit data. Design: The study was a realist evaluation and biography of artefacts study. Setting: The study involved five NHS acute trusts. Methods and results: In phase 1, we developed a theory of national audits through interviews. Data use was supported by data access, audit staff skilled to produce data visualisations, data timeliness and quality, and the importance of perceived metrics. Data were mainly used by clinical teams. Organisational-level staff questioned the legitimacy of national audits. In phase 2, QualDash was co-designed and the QualDash theory was developed. QualDash provides interactive customisable visualisations to enable the exploration of relationships between variables. Locating QualDash on site servers gave users control of data upload frequency. In phase 3, we developed an adoption strategy through focus groups. ‘Champions’, awareness-raising through e-bulletins and demonstrations, and quick reference tools were agreed. In phase 4, we tested the QualDash theory using a mixed-methods evaluation. Constraints on use were metric configurations that did not match users’ expectations, affecting champions’ willingness to promote QualDash, and limited computing resources. Easy customisability supported use. The greatest use was where data use was previously constrained. In these contexts, report preparation time was reduced and efforts to improve data quality were supported, although the interrupted time series analysis did not show improved data quality. Twenty-three questionnaires were returned, revealing positive perceptions of ease of use and usefulness. In phase 5, the feasibility of conducting a cluster randomised controlled trial of QualDash was assessed. Interviews were undertaken to understand how QualDash could be revised to support a region-wide Gold Command. Requirements included multiple real-time data sources and functionality to help to identify priorities. Conclusions: Audits seeking to widen engagement may find the following strategies beneficial: involving a range of professional groups in choosing metrics; real-time reporting; presenting ‘headline’ metrics important to organisational-level staff; using routinely collected clinical data to populate data fields; and dashboards that help staff to explore and report audit data. Those designing dashboards may find it beneficial to include the following: ‘at a glance’ visualisation of key metrics; visualisations configured in line with existing visualisations that teams use, with clear labelling; functionality that supports the creation of reports and presentations; the ability to explore relationships between variables and drill down to look at subgroups; and low requirements for computing resources. Organisations introducing a dashboard may find the following strategies beneficial: clinical champion to promote use; testing with real data by audit staff; establishing routines for integrating use into work practices; involving audit staff in adoption activities; and allowing customisation. Limitations: The COVID-19 pandemic stopped phase 4 data collection, limiting our ability to further test and refine the QualDash theory. Questionnaire results should be treated with caution because of the small, possibly biased, sample. Control sites for the interrupted time series analysis were not possible because of research and development delays. One intervention site did not submit data. Limited uptake meant that assessing the impact on more measures was not appropriate. Future work: The extent to which national audit dashboards are used and the strategies national audits use to encourage uptake, a realist review of the impact of dashboards, and rigorous evaluations of the impact of dashboards and the effectiveness of adoption strategies should be explored. Study registration: This study is registered as ISRCTN18289782. / This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme and will be published in full in Health and Social Care Delivery Research; Vol. 10, No. 12. See the NIHR Journals Library website for further project information.

The internet has radically changed the way people obtain and interact with information about diseases, treatments, and conditions. Yet, our understanding of how people access and use health information to make decisions- in other words, their health literacy- has not progressed. The overall aim of this thesis is to assess the extent to which health literacy is a valid and useful construct for policy and practice related to online health resources. A mixed-methods research programme of five studies was undertaken, influenced by realist evaluation methodology. First, to ascertain engagement with user-generated online health content (UGC) in the UK, analysis of a large European survey was undertaken. Then, the uncertainty regarding the relationship between health literacy and outcomes was addressed by a systematic review and qualitative analysis of health literacy measures. Results of these two studies informed interviews carried out with 13 'key informants': policymakers and primary care clinicians in the UK with a particular interest in health literacy and/or online information. A systematic review, incorporating a traditional narrative review and a realist review, evaluated existing trials addressing how effects of online resources vary by health literacy level. Finally, data were analysed from a feasibility randomized controlled trial, comparing usage and outcomes of accessing a 'personal experiences'-based asthma website (representing curated user-generated content) versus a 'facts and figures'-based website. Participant health literacy was assessed using an index identified from the systematic review of measures, and website usage was tracked. Approximately 25% of UK internet users engage with UGC at least monthly. The most frequent users were younger, more likely to be male, and to be carers for someone with a long-term illness. Three themes were identified from health literacy measurement: 'appropriate health decisions', 'ability to obtain healthcare services', and 'confidence'. Key informants noted the lack of clarity about how health literacy influences outcomes, and suggested that personal preferences and digital access and skills may be more relevant than health literacy for policy and practice. Existing trials of online resources in which participant health literacy was measured were mostly at high risk of bias; some possible explanations of how these interventions should work in people with low health literacy were that they may experience higher data entry burden related to chronic diseases, and that they may prefer simulated face-to-face communication. Finally, there were no differences between health literacy groups in the feasibility trial regarding usage or outcomes related to either the 'facts and figures' or 'personal experiences' websites. Taken together, these results question the validity and appropriateness of health literacy as a key objective or consideration in the development or use of online resources. While health literacy has value as a general idea, this thesis demonstrates that it may no longer be the right construct to guide intervention development and implementation to improve health outcomes.