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Yes / The majority of people with dementia in the UK die in care homes. The quality of end of life care in these environments is often suboptimal. The aim of the present study was to explore the context, mechanisms and outcomes for providing good palliative care to people with advanced dementia residing in UK care homes from the perspective of health and social care providers. Method: The design of the study was qualitative which involved purposive sampling of health care professionals to undertake interactive interviews within a realist framework. Interviews were completed between September 2012 and October 2013 and were thematically analysed and then conceptualised according to context, mechanisms and outcomes. The settings were private care homes and services provided by the National Health Service including memory clinics, mental health and commissioning services in London, United Kingdom. The participants included 14 health and social care professionals including health care assistants, care home managers, commissioners for older adults’ services and nursing staff. Results: Good palliative care for people with advanced dementia is underpinned by the prioritisation of psychosocial and spiritual care, developing relationships with family carers, addressing physical needs including symptom management and continuous, integrated care provided by a multidisciplinary team. Contextual factors that detract from good end of life care included: an emphasis on financial efficiency over person-centred care; a complex health and social care system, societal and family attitudes towards staff; staff training and experience, governance and bureaucratisation; complexity of dementia; advance care planning and staff characteristics. Mechanisms that influence the quality of end of life care include: level of health care professionals’ confidence, family uncertainty about end of life care, resources for improving end of life care and supporting families, and uncertainty about whether dementia specific palliative care is required. Conclusions: Contextual factors regarding the care home environment may be obdurate and tend to negatively impact on the quality of end of life dementia care. Local level mechanisms may be more amenable to improvement. However, systemic changes to the care home environment are necessary to promote consistent, equitable and sustainable high quality end of life dementia care across the UK care home sector

Yes / In the United Kingdom, stroke is the most significant cause of adult disability. Stroke survivors are frequently left with physical and psychological changes that can profoundly affect their functional ability, independence, and social participation. Research suggests that long-term, intense, task- and context-specific rehabilitation that is goal-oriented and environmentally enriched improves function, independence, and quality of life after a stroke. It is recommended that rehabilitation should continue until maximum recovery has been achieved. However, the increasing demand on services and financial constraints means that needs cannot be met through traditional face-to-face delivery of rehabilitation. Using a participatory design methodology, we developed an information communication technology–enhanced Personalized Self-Managed rehabilitation System (PSMrS) for stroke survivors with integrated insole sensor technology within an “intelligent shoe.”. The intervention model was based around a rehabilitation paradigm underpinned by theories of motor relearning and neuroplastic adaptation, motivational feedback, self-efficacy, and knowledge transfer. To understand the conditions under which this technology-based rehabilitation solution would most likely have an impact on the motor behavior of the user, what would work for whom, in what context, and how. We were interested in what aspects of the system would work best to facilitate the motor behavior change associated with self-managed rehabilitation and which user characteristics and circumstances of use could promote improved functional outcomes. Methods: We used a Realist Evaluation (RE) framework to evaluate the final prototype PSMrS with the assumption that the intervention consists of a series of configurations that include the Context of use, the underlying Mechanisms of change and the potential Outcomes or impacts (CMOs). We developed the CMOs from literature reviews and engagement with clinicians, users, and caregivers during a series of focus groups and home visits. These CMOs were then tested in five in-depth case studies with stroke survivors and their caregivers. Results: While two new propositions emerged, the second importantly related to the self-management aspects of the system. The study revealed that the system should also encourage independent use and the setting of personalized goals or activities. Conclusions: Information communication technology that purports to support the self-management of stroke rehabilitation should give significant consideration to the need for motivational feedback that provides quantitative, reliable, accurate, context-specific, and culturally sensitive information about the achievement of personalized goal-based activities.

Yes / Safe and successful surgery depends on effective teamwork between professional groups, each playing their part in a complex division of labour. This article reports the first empirical examination of how introduction of robot-assisted surgery changes the division of labour within surgical teams and impacts teamwork and patient safety. Data collection and analysis was informed by realist principles. Interviews were conducted with surgical teams across nine UK hospitals and, in a multi-site case study across four hospitals, data were collected using a range of methods, including ethnographic observation, video recording and semi-structured interviews. Our findings reveal that as the robot enables the surgeon to do more, the surgical assistant's role becomes less clearly defined. Robot-assisted surgery also introduces new tasks for the surgical assistant and scrub practitioner, in terms of communicating information to the surgeon. However, the use of robot-assisted surgery does not redistribute work in a uniform way; contextual factors of individual experience and team relationships shape changes to the division of labour. For instance, in some situations, scrub practitioners take on the role of supporting inexperienced surgical assistants. These changes in the division of labour do not persist when team members return to operations that are not robot-assisted. This study contributes to wider literature on divisions of labour in healthcare and how this is impacted by the introduction of new technologies. In particular, we emphasise the need to pay attention to often neglected micro-level contextual factors. This can highlight behaviours that can be promoted to benefit patient care.

Yes / National Clinical Audits (NCAs) are a well-established quality improvement strategy used in healthcare settings. Significant resources, including clinicians’ time, are invested in participating in NCAs, yet there is variation in the extent to which the resulting feedback stimulates quality improvement. The aim of this study was to explore the reasons behind this variation. Methods We used realist evaluation to interrogate how context shapes the mechanisms through which NCAs work (or not) to stimulate quality improvement. Fifty-four interviews were conducted with doctors, nurses, audit clerks and other staff working with NCAs across five healthcare providers in England. In line with realist principles we scrutinised the data to identify how and why providers responded to NCA feedback (mechanisms), the circumstances that supported or constrained provider responses (context), and what happened as a result of the interactions between mechanisms and context (outcomes). We summarised our findings as Context+Mechanism=Outcome configurations. Results We identified five mechanisms that explained interactions between providers and NCA feedback: reputation, professionalism, competition, incentives, and professional development. Underpinned by the mechanisms professionalism and incentives, feedback was used most routinely within clinical services resourced to maintain local databases, where data were stored before upload to NCA suppliers. Local databases enabled staff to access data easily, customise reports and integrate them within governance processes. Use of feedback generated in this way was further supported where staff supporting audit participation were trusted to collect timely and accurate data. Feedback produced by NCA suppliers, which included national comparator data, was used in a more limited capacity. Challenges accessing data from NCA supplier databases, concerns about the quality of data across participating organisations and timeliness were reported to constrain the perceived usefulness of this type of feedback as a tool for stimulating quality improvement. Conclusion The findings suggest that there are a number of mechanisms through which healthcare providers, in particular staff within clinical services, engage with NCA feedback, but that there is variation in the mode, frequency and impact of these interactions. Feedback was used most routinely within clinical services resourced to maintain local databases, where data were considered timely, trusted as accurate and could be easily accessed to customise reports for the needs of the service.

Yes / Health services in many countries are investing in inter-organisational networks, linking patients’ records held in different organisations across a city or region. The aim of the systematic review was to establish how, why, and in what circumstances these networks improve patient safety, fail to do so, or increase safety risks, for people living at home. Design Realist synthesis, drawing on both quantitative and qualitative evidence, and including consultation with stakeholders in nominal groups and semi-structured interviews. Eligibility criteria The co-ordination of services for older people living at home, and medicine reconciliation for older patients returning home from hospital. Information sources 17 sources including Medline, Embase, CINAHL, Cochrane Library, Web of Science, ACM Digital Library and Applied Social Sciences Index and s (ASSIA). Outcomes Changes in patients’ clinical risks. Results We did not find any detailed accounts of the sequences of events that policy makers and others believe will lead from the deployment of interoperable networks to improved patient safety. We were, though, able to identify a substantial number of theory fragments, and these were used to develop programme theories. There is good evidence that there are problems with the co-ordination of services in general, and the reconciliation of medication lists in particular, and it indicates that most problems are social and organisational in nature. There is also good evidence that doctors and other professionals find interoperable networks difficult to use. There was limited high quality evidence about safety-related outcomes associated with the deployment of interoperable networks. Conclusions Empirical evidence does not currently justify claims about the beneficial effects of interoperable networks on patient safety. There appears to be a mismatch between technology-driven assumptions about the effects of networks and the socio-technical nature of co-ordination problems. Review registration: PROSPERO CRD42017073004 / NIHR Grant 16/53/03

Yes / Engaging in regular physical activity requires continued complex decision-making in varied and dynamic individual, social and structural contexts. Widespread shortfalls of physical activity interventions suggests the complex underlying mechanisms of change are not yet fully understood. More insightful process evaluations are needed to design and implement more effective approaches. This paper describes the protocol for a process evaluation of the JU:MP programme, a whole systems approach to increasing physical activity in children and young people aged 5-14 years in North Bradford, UK. This process evaluation, underpinned by realist philosophy, aims to understand the development and implementation of the JU:MP programme and the mechanisms by which JU:MP influences physical activity in children and young people. It also aims to explore behaviour change across wider policy, strategy and neighbourhood systems. A mixed method data collection approach will include semi-structured interview, observation, documentary analysis, surveys, and participatory evaluation methods including reflections and ripple effect mapping. This protocol offers an innovative approach on the use of process evaluation feeding into an iterative programme intended to generate evidence-based practice and deliver practice-based evidence. This paper advances knowledge regarding the development of process evaluations for evaluating systems interventions, and emphasises the importance of process evaluation. / Sport England's Local Delivery Pilot - Bradford

Yes / Heel pressure ulcers can cause pain, reduce mobility, lead to longer hospital stays and in severe cases can lead to sepsis, amputation, and death. Offloading boots are marketed as heel pressure ulcer prevention devices, working by removing pressure to the heel, yet there is little good quality evidence about their clinical effectiveness. Given that evidence is not guiding use of these devices, this study aims to explore, how, when, and why these devices are used in hospital settings. To explore how offloading devices are used to prevent heel pressure ulcers, for whom and in what circumstances. A realist evaluation was undertaken to explore the contexts, mechanisms, and outcomes that might influence how offloading devices are implemented and used in clinical practice for the prevention of heel pressure ulcers in hospitals. Eight Tissue Viability Nurse Specialists from across the UK (England, Wales, and Northern Ireland) were interviewed. Questions sought to elicit whether, and in what ways, initial theories about the use of heel pressure ulcers fitted with interviewee's experiences. Thirteen initial theories were refined into three programme theories about how offloading devices are used by nurses 'proactively' to prevent heel pressure ulcers, 'reactively' to treat and minimise deterioration of early-stage pressure ulcers, and patient factors that influence how these devices are used. Offloading devices were used in clinical practice by all the interviewees. It was viewed that they were not suitable to be used by every patient, at every point in their inpatient journey, nor was it financially viable. However, the interviewees thought that identifying suitable 'at risk' patient groups that can maintain use of the devices could lead to proactive and cost-effective use of the devices. This understanding of the contexts and mechanisms that influence the effective use of offloading devices has implications for clinical practice and design of clinical trials of offloading devices. How, for whom, and in what circumstances do offloading devices work to prevent heel pressure ulcers? Tissue viability nurses' perspectives. / CG conducted this review as part of her PhD at the University of Leeds which was funded by a Charitable Grant from https://leedscares.org/LeedsHospitalsCharity (https://www.leedshospitalscharity. org.uk/) and Smith and Nephew Foundation.

L’implication des volontaires de santé communautaire, tels que les volontaires de la Fédération Internationale des Sociétés de la Croix-Rouge et du Croissant-Rouge, peut constituer un moyen approprié de s’attaquer au problème d’inégalités sociales et de santé. Pourtant, les connaissances manquent sur ce qui marche pour améliorer la performance des volontaires. Objectifs Comprendre comment, pourquoi, pour quels volontaires et dans quelles circonstances les stratégies organisationnelles mises en œuvre pour améliorer la performance des volontaires de santé communautaire marchent. Méthodes En raison de la complexité des programmes impliquant des volontaires de santé communautaire, nous avons adopté l’évaluation réaliste comme approche méthodologique et l’étude de cas comparative comme modèle d’étude. Dans un premier temps, des entretiens, une synthèse réaliste de la littérature ainsi qu’une revue des théories d’action qui sous-tendent ces programmes ont été réalisés pour développer le cadre théorique de l’évaluation. Ensuite, deux cas ont été sélectionnés sur Kampala, la capitale de l’Ouganda, ou la Société Nationale de la Croix-Rouge et du Croissant-Rouge Ougandaise développe des stratégies pour améliorer la performance des volontaires. Chaque cas correspond à une unité organisationnelle de la Société Nationale Ougandaise, responsable de la mise en place des programmes de santé au niveau d’un district du pays. Les méthodes de collecte de données ont inclus des entretiens individuels, des groupes de discussion, des observations, ainsi qu’une revue de documents. Un processus méthodologique de comparaison constante a été utilisé pour l’analyse des données. Résultats Les stratégies d’intervention, dont les pratiques managériales peuvent influencer positivement la performance lorsqu’elles favorisent la satisfaction des besoins psychologiques des volontaires (l’autonomie, la responsabilisation, la compétence et le lien social). Pour ce faire, les stratégies et leur mise en œuvre doivent s’adapter aux différentes formes de motivation des volontaires et à l’évolution de celles-ci pendant le volontariat. S’agissant du contexte, la reconnaissance communautaire et la reconnaissance organisationnelle sont deux facteurs clés qui interviennent dans la satisfaction des besoins psychologiques des volontaires. Discussion Cette recherche doctorale a des implications pour la Fédération Internationale des Sociétés de la Croix Rouge et du Croissant Rouge. Les résultats fournissent des informations utiles à l’action relative à la mise en place de programmes de volontaires de santé communautaire et l’approche évaluative a des implications générales en ce qui concerne la dynamique d’apprentissage organisationnel. Par ailleurs l’approche de l’évaluation réaliste a également contribué, à sa mesure, au développement du champ de l’évaluation de programme en santé. L’opérationnalisation des concepts de l’approche réaliste a été discutée et approfondie afin de contribuer au développement de cette approche. / Context The recruitment of community health volunteers, such as the volunteers of the International Federation of Red Cross and Red Crescent Society, is an established approach to improve the health of underserved communities. However, there is a dearth of evidence about what works to improve volunteers’ performance. Objectives To understand why, how, for which volunteers and under which circumstances intervention approaches to improve volunteers’ performance is more likely to be successful. Methods Given the complexity of the intervention under study, a realist evaluation as methodological approach and a case study as study design was adopted. Firstly, a realist review together with interviews with the main stakeholders and a review of the theories underlying community health volunteers programme have been conducted to develop the theoretical basis for the evaluation. Secondly for the case study, two contrasted cases have been then selected at district level in the capital of Uganda, where the Red Cross Society is implementing a community-based programme. A case is as a Red Cross unit run by a programme manager that operate around one governmental district structures. Data collection included document review, participant observation and interviews. The constant comparative method was used for the analysis. Results Intervention approaches that include supervision supportive of autonomy, skills and knowledge enhancement and that is adapted to the different sub-groups of volunteers, leads to satisfaction of the three key drivers of volunteer motivation: feelings of autonomy, of competence and of connectedness. This contributes to volunteers’ better performance. Enabling contextual conditions include the responsiveness of the organisation to community needs and recognition from the organisation and the community of the work of the volunteers. Discussion The findings will inform the management of community health volunteers and have implication for the International Federation of Red Cross and Red Crescent Societies regrading organisational learning. It also contributed to building the field of programme evaluation in Health and led to methodological developments for doing realist evaluation.