Senior medical students as assistants in medicine in COVID-19 crisis: a realist evaluation protocol

IntroductionThe assistant in medicine is a new and paid role for final-year medical students that has been established in New South Wales, Australia, as part of the surge workforce management response to the COVID-19 pandemic. Eligibility requires the applicant to be a final-year medical student in an Australian Medical Council-accredited university and registered with the Australian Health Practitioner Regulation Agency. While there are roles with some similarities to the assistant in medicine role, such as assistantships (the UK) and physician assistants adopted internationally, this is completely new in Australia. Little is known about the functionality and success factors of this role within the health practitioner landscape, particularly within the context of the COVID-19 pandemic. Given the complexity of this role, a realist approach to evaluation has been undertaken as described in this protocol, which sets out a study design spanning from August 2020 to June 2021.Methods and analysisThe intention of conducting a realist review is to identify the circumstances and mechanisms that determine the outcomes of the assistant in medicine intervention. We will start by developing an initial programme theory to explore the potential function of the assistant in medicine role through realist syntheses of critically appraised summaries of existing literature using relevant databases and journals. Other data sources such as interviews and surveys with key stakeholders will contribute to the refinements of the programme theory. Using this method, we will develop a set of hypotheses on how and why the Australian assistants in medicine intervention might ‘work’ to achieve a variety of outcomes based on examples of related international interventions. These hypotheses will be tested against the qualitative and quantitative evidence gathered from all relevant stakeholders.Ethics and disseminationEthics approval for the larger study was obtained from the Western Sydney Local Health District (2020/ETH01745). The findings of this review will provide useful information for hospital managers, academics and policymakers, who can apply the findings in their context when deciding how to implement and support the introduction of assistants in medicine into the health system. We will publish our findings in reports to policymakers, peer-reviewed journals and international conferences.

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Protocol for the impact of paramedics in NHS primary care: application of realist approaches to improve understanding and support intelligent policy and future workforce planning

British Paramedic Journal ◽

10.29045/14784726.2019.12.4.3.35 ◽

2019 ◽

Vol 4 (3) ◽

pp. 35-42 ◽

Cited By ~ 1

Author(s):

Georgette Eaton ◽

Veronika Williams ◽

Geoff Wong ◽

Nia Roberts ◽

Kamal R. Mahtani

Keyword(s):

Primary Care ◽

Life Support ◽

Evidence Synthesis ◽

Workforce Planning ◽

Advanced Life Support ◽

Realist Review ◽

Professional Associations ◽

Realist Evaluation ◽

Programme Theory ◽

The Impact

Introduction: In the United Kingdom, changing demands on ambulance services has caused a change in what is expected of a paramedic. As well as advanced life support, paramedics now need to be skilled in managing a range of urgent case presentations, with emphasis on treat-at-scene. The change in the scope of work paramedics can undertake has established their role within primary care. However, as paramedics transition to roles within primary care, their knowledge and skillset will undoubtedly need to change. The current opportunities for paramedics’ employment in primary care require careful evaluation. In order to contribute to patients’ and the NHS’ primary care agenda, evidence must be generated to show how and why these changes would work, for whom, in what context and to what extent.Methods and analysis: The purpose of this research is to produce findings that will improve our understanding of the ways in which (i.e. how, why and in what contexts) paramedics impact on the primary care workforce. A theory-driven approach to evidence-synthesis will be conducted in a realist review, to produce a programme theory. This programme theory will be tested using empirical data collected through a realist evaluation. Survey and interview data will be collected from paramedics working in primary care, general practitioners and patients to assess under which contexts, and by which mechanisms, paramedics are working in primary care, and thus test the programme theory. Based on the findings, we will be able to highlight the role of paramedics in primary care, as well as how they operate and under what conditions.Ethics and dissemination: Formal ethics review is not required for the review, as it is secondary research, but will be sought for the evaluation. Findings will be disseminated in a peer-reviewed journal, at national and international conferences and to relevant professional associations.

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Unpacking the black box of the effectiveness of task forces in maternal and neonatal health in Morocco : A realist evaluation protocol

10.21203/rs.3.rs-280390/v1 ◽

2021 ◽

Author(s):

Zakaria Belrhiti ◽

Rachid Moulki ◽

Safwane Mowafaq ◽

Hassan Chrifi ◽

Bouchra Assarag

Keyword(s):

Health Systems ◽

Local Community ◽

Governance Structure ◽

Realist Evaluation ◽

Regional Governance ◽

Neonatal Health ◽

Local Health ◽

Programme Theory ◽

Task Forces ◽

Maternal And Neonatal Health

Abstract Background In low and middle incomes countries (LMICs), health policies failed to reduce significantly maternal and neonatal mortality rates. This was attributed to inequitable access to care and to poor governance of local health systems. In Morocco, there are still regional disparities with access to maternal care, and poor governance of regional maternal and neonatal health programmes (RMNHP). To address these governance issues, the ministry of health implemented in 2017 a multi-actor’s governance structure called “regional task forces”(RTF). They aim at enabling collective concerted actions, active engagement of local community partners and better coordination between health systems managers and frontline workers in the monitoring, assessment and implementation of RMNHP. In this study, we aimed at analysing how regional taskforces were implemented in six heath regions and identify the mechanisms and contextual conditions underlying their effectiveness.Methods We adopted the realist evaluation as a suitable approach to decipher complex intertwined social phenomena. We adopted a multiple embedded case study design that allows a flexible exploration of different levels of analysis and takes into consideration the role of context. First, we developed an initial programme theory based on a literature review and policy document analysis as follows: ”A taskforce is effective whenever there is a fit between its intrinsic technocratic, political, democratic and learning capacities and the characteristics of the institutional context, the complexity of health problems and the engagement and leadership of actors”. Our programme theory will be refined using 10 to 12 individual interviews (IDI) with policy implementers. We will use secondary documents, and 4 to 6 interviews with taskforces members (clinicians, managers, and midwives). We will then carry two in-depth case studies in one low and one high performing taskforce using additional 6 to 12 interviews, 3 focus group discussions with senior managers, clinicians, and midwives. Qualitative data analysis will be informed by Intervention Context Actor Mechanism Outcome (ICAMO) hypothesis coding. We will then compare the different ICAMOs across cases using qualitative comparative analysis . DiscussionThe resulting programme theory will guide the reinforcement of regional governance of MNH programmes in Morocco.

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Making healthcare accessible for single adults with complex needs experiencing long-term homelessness: A realist evaluation protocol

HRB Open Research ◽

10.12688/hrbopenres.13154.2 ◽

2021 ◽

Vol 3 ◽

pp. 73

Author(s):

Rikke Siersbaek ◽

John Ford ◽

Clíona Ní Cheallaigh ◽

Sara Burke ◽

Steve Thomas

Keyword(s):

Health System ◽

Performance Management ◽

System Performance ◽

Realist Review ◽

Realist Evaluation ◽

System Level ◽

Health System Performance ◽

Programme Theory ◽

Healthcare Accessibility

Background: Over the last several years, homelessness has increased in Ireland and across Europe. Rates have recently declined since the coronavirus disease 2019 (COVID-19) pandemic, but it is unclear whether emergency housing measures will remain in place permanently. Populations experiencing long-term homelessness face a higher burden of multi-morbidity at an earlier age than housed populations and have poorer health outcomes. However, this population also has more difficulty accessing appropriate health services. A realist review by the authors found that important health system contexts which impact access are resourcing, training, funding cycles, health system fragmentation, health system goals, how care is organised, culture, leadership and flexibility of care delivery. Using a realist evaluation approach, this research will explore and refine key system-level factors, highlighted in our realist review, in a local health care system. Aim: The aim of this study is to understand how funding procedures and health system performance management impact service settings, staff, providers and their ability to make services accessible to populations experiencing homelessness. Methods: A realist evaluation will be undertaken to explain how funding and health system performance management impact healthcare accessibility for populations experiencing homelessness. Data will be collected using qualitative and realist interview techniques and focus group methodology. Secondary data such as policy documents and budgets will utilised. The analysis will follow Pawson and Tilley’s iterative phases starting with building an Initial programme theory, then data collection, data analysis, synthesis and finally building a refined programme theory. Conclusion: Building on a realist review conducted by the same research team, this study will further test and refine findings that explain how health system factors impact healthcare accessibility for populations experiencing homelessness. The study has the potential to inform policy makers, health planners and managers of contextual factors that can be modified to increase healthcare accessibility.

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How accessible is healthcare for single adults experiencing long-term homelessness and complex needs? A realist evaluation protocol

HRB Open Research ◽

10.12688/hrbopenres.13154.1 ◽

2020 ◽

Vol 3 ◽

pp. 73 ◽

Cited By ~ 1

Author(s):

Rikke Siersbaek ◽

John Ford ◽

Clíona Ní Cheallaigh ◽

Sara Burke ◽

Steve Thomas

Keyword(s):

Health System ◽

Performance Management ◽

System Performance ◽

Realist Review ◽

Realist Evaluation ◽

System Level ◽

Health System Performance ◽

Programme Theory ◽

Healthcare Accessibility

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The Duties of Doctors In Medical Education: A Letter To The Editor (Preprint)

10.2196/preprints.16418 ◽

2019 ◽

Author(s):

Sneha Barai

Keyword(s):

Medical Education ◽

Medical Students ◽

Role Models ◽

Role Model ◽

General Medical Council ◽

Future Generations ◽

Medical Council ◽

Positive Role ◽

The Uk ◽

And Training

UNSTRUCTURED The UK General Medical Council (GMC) explicitly states doctors have a duty to ‘contribute to teaching and training…by acting as a positive role model’. However, recent studies suggest some are not fulfilling this, which is impacting medical students' experiences and attitudes during their training. As such, doctors have a duty to act as role models and teachers, as specified by the GMC, which it seems are not currently being fulfilled. This would improve the medical students’ learning experiences and demonstrate good professional values for them to emulate. Therefore, these duties should be as important as patient care, since this will influence future generations.

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Upskilling health and care workers with augmented and virtual reality: protocol for a realist review to develop an evidence-informed programme theory

BMJ Open ◽

10.1136/bmjopen-2021-050033 ◽

2021 ◽

Vol 11 (7) ◽

pp. e050033

Author(s):

Norina Gasteiger ◽

Sabine N van der Veer ◽

Paul Wilson ◽

Dawn Dowding

Keyword(s):

Virtual Reality ◽

Grey Literature ◽

Healthcare Providers ◽

Realist Review ◽

Relevant Information ◽

Care Providers ◽

Programme Theory ◽

Clinical Educators ◽

Continued Learning ◽

Search Quality

IntroductionAugmented reality (AR) and virtual reality (VR) are increasingly used to upskill health and care providers, including in surgical, nursing and acute care settings. Many studies have used AR/VR to deliver training, providing mixed evidence on their effectiveness and limited evidence regarding contextual factors that influence effectiveness and implementation. This review will develop, test and refine an evidence-informed programme theory on what facilitates or constrains the implementation of AR or VR programmes in health and care settings and understand how, for whom and to what extent they ‘work’.Methods and analysisThis realist review adheres to the Realist And Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) standards and will be conducted in three steps: theory elicitation, theory testing and theory refinement. First, a search will identify practitioner, academic and learning and technology adoption theories from databases (MEDLINE, Scopus, CINAHL, Embase, Education Resources Information Center, PsycINFO and Web of Science), practitioner journals, snowballing and grey literature. Information regarding contexts, mechanisms and outcomes will be extracted. A narrative synthesis will determine overlapping configurations and form an initial theory. Second, the theory will be tested using empirical evidence located from the above databases and identified from the first search. Quality will be assessed using the Mixed Methods Appraisal Tool (MMAT), and relevant information will be extracted into a coding sheet. Third, the extracted information will be compared with the initial programme theory, with differences helping to make refinements. Findings will be presented as a narrative summary, and the MMAT will determine our confidence in each configuration.Ethics and disseminationEthics approval is not required. This review will develop an evidence-informed programme theory. The results will inform and support AR/VR interventions from clinical educators, healthcare providers and software developers. Upskilling through AR/VR learning interventions may improve quality of care and promote evidence-based practice and continued learning. Findings will be disseminated through conference presentations and peer-reviewed journal articles.

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How rural immersion training influences rural work orientation of medical students: Theory building through realist evaluation

Medical Teacher ◽

10.1080/0142159x.2021.1948520 ◽

2021 ◽

pp. 1-8

Author(s):

Amie Bingham ◽

Belinda O’Sullivan ◽

Danielle Couch ◽

Samuel Cresser ◽

Matthew McGrail ◽

...

Keyword(s):

Medical Students ◽

Realist Evaluation ◽

Theory Building ◽

Work Orientation ◽

Immersion Training ◽

Rural Work

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Contexts and mechanisms that promote access to healthcare for populations experiencing homelessness: a realist review

BMJ Open ◽

10.1136/bmjopen-2020-043091 ◽

2021 ◽

Vol 11 (4) ◽

pp. e043091

Author(s):

Rikke Siersbaek ◽

John Alexander Ford ◽

Sara Burke ◽

Clíona Ní Cheallaigh ◽

Steve Thomas

Keyword(s):

Health System ◽

Healthcare Access ◽

Grey Literature ◽

Realist Review ◽

Access To Healthcare ◽

Staff Retention ◽

Programme Theory ◽

Eligibility Criteria ◽

Ovid Medline ◽

High Level

ObjectiveThe objective of this study was to identify and understand the health system contexts and mechanisms that allow for homeless populations to access appropriate healthcare when needed.DesignA realist review.Data sourcesOvid MEDLINE, embase.com, CINAHL, ASSIA and grey literature until April 2019.Eligibility criteria for selecting studiesThe purpose of the review was to identify health system patterns which enable access to healthcare for people who experience homelessness. Peer-reviewed articles were identified through a systematic search, grey literature search, citation tracking and expert recommendations. Studies meeting the inclusion criteria were assessed for rigour and relevance and coded to identify data relating to contexts, mechanisms and/or outcomes.AnalysisInductive and deductive coding was used to generate context–mechanism–outcome configurations, which were refined and then used to build several iterations of the overarching programme theory.ResultsSystematic searching identified 330 review articles, of which 24 were included. An additional 11 grey literature and primary sources were identified through citation tracking and expert recommendation. Additional purposive searching of grey literature yielded 50 records, of which 12 were included, for a total of 47 included sources. The analysis found that healthcare access for populations experiencing homelessness is improved when services are coordinated and delivered in a way that is organised around the person with a high degree of flexibility and a culture that rejects stigma, generating trusting relationships between patients and staff/practitioners. Health systems should provide long-term, dependable funding for services to ensure sustainability and staff retention.ConclusionsWith homelessness on the rise internationally, healthcare systems should focus on high-level factors such as funding stability, building inclusive cultures and setting goals which encourage and support staff to provide flexible, timely and connected services to improve access.

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Behaviour change practices in exercise referral schemes: developing realist programme theory of implementation

BMC Health Services Research ◽

10.1186/s12913-021-06349-9 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

John Downey ◽

Katie Shearn ◽

Nicola Brown ◽

Ross Wadey ◽

Jeff Breckon

Keyword(s):

Behaviour Change ◽

Theoretical Domains Framework ◽

Developed Countries ◽

Realist Evaluation ◽

Service Planning ◽

Service Development ◽

Activity Levels ◽

Programme Theory ◽

Implementation Framework ◽

Exercise Referral

Abstract Background Exercise Referral Schemes have been delivered worldwide in developed countries to augment physical activity levels in sedentary patients with a range of health issues, despite their utility being questioned. Understanding the implementation mechanisms of behaviour change practices is important to avoid inappropriate decommissioning and support future service planning. The aim of this study was to develop initial theories to understand what influences the behaviour change practices of Exercise Referral practitioners within the United Kingdom. Methods An eight-month focused ethnography was undertaken, to carry out the first phase of a realist evaluation, which included participant observation, interviews, document analysis, and reflexive journaling. A comprehensive implementation framework (Consolidated Framework for Implementation Research) was adopted providing an extensive menu of determinants. Mechanisms were categorised based on the Theoretical Domains Framework (within the Capability, Opportunity, Motivation, Behaviour model) providing an explanatory tool linking the levels of the framework. Results Three programme theories are proposed. Firstly, motivation and capability are influenced when behaviour change oriented planning and training are in place. Secondly, motivation is influenced if leadership is supportive of behaviour change practice. Lastly, integration between health professionals and practitioners will influence motivation and capability. The conditions necessary to influence motivation and capability include a person-centred climate, cognizant practitioners, and established communities of practice. Conclusions The findings are the first to articulate the necessary elements for the implementation of behaviour change practices in Exercise Referral services. These results outline emerging theories about the conditions, resources, and explanations of behaviour change implementation that can inform service development.

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Conversations about FGM in primary care: a realist review on how, why and under what circumstances FGM is discussed in general practice consultations

BMJ Open ◽

10.1136/bmjopen-2020-039809 ◽

2021 ◽

Vol 11 (3) ◽

pp. e039809

Author(s):

Sharon Dixon ◽

Claire Duddy ◽

Gabrielle Harrison ◽

Chrysanthi Papoutsi ◽

Sue Ziebland ◽

...

Keyword(s):

Primary Care ◽

Grey Literature ◽

Relevant Literature ◽

Theory Development ◽

Realist Review ◽

Primary Outcome Measure ◽

Mandatory Reporting ◽

Programme Theory ◽

Genital Mutilation ◽

The Impact

ObjectivesLittle is known about the management of female genital mutilation (FGM) in primary care. There have been significant recent statutory changes relevant to general practitioners (GPs) in England, including a mandatory reporting duty. We undertook a realist synthesis to explore what influences how and when GPs discuss FGM with their patients.SettingPrimary care in England.Data sourcesRealist literature synthesis searching 10 databases with terms: GPs, primary care, obstetrics, gynaecology, midwifery and FGM (UK and worldwide). Citation chasing was used, and relevant grey literature was included, including searching FGM advocacy organisation websites for relevant data. Other potentially relevant literature fields were searched for evidence to inform programme theory development. We included all study designs and papers that presented evidence about factors potentially relevant to considering how, why and in what circumstances GPs feel able to discuss FGM with their patients.Primary outcome measureThis realist review developed programme theory, tested against existing evidence, on what influences GPs actions and reactions to FGM in primary care consultations and where, when and why these influences are activated.Results124 documents were included in the synthesis. Our analysis found that GPs need knowledge and training to help them support their patients with FGM, including who may be affected, what needs they may have and how to talk sensitively about FGM. Access to specialist services and guidance may help them with this role. Reporting requirements may complicate these conversations.ConclusionsThere is a pressing need to develop (and evaluate) training to help GPs meet FGM-affected communities’ health needs and to promote the accessibility of primary care. Education and resources should be developed in partnership with community members. The impact of the mandatory reporting requirement and the Enhanced Dataset on healthcare interactions in primary care warrants evaluation.PROSPERO registration numberCRD42018091996.

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