scholarly journals Understanding the role of the paramedic in primary care: a realist review

BMC Medicine ◽  
2021 ◽  
Vol 19 (1) ◽  
Author(s):  
Georgette Eaton ◽  
Geoff Wong ◽  
Stephanie Tierney ◽  
Nia Roberts ◽  
Veronika Williams ◽  
...  

Abstract Background Since 2002, paramedics have been working in primary care within the United Kingdom (UK), a transition also mirrored within Australia, Canada and the USA. Recent recommendations to improve UK NHS workforce capacities have led to a major push to increase the numbers of paramedics recruited into primary care. However, gaps exist in the evidence base regarding how and why these changes would work, for whom, in what context and to what extent. To understand the ways in which paramedics impact (or not) the primary care workforce, we conducted a realist review. Methods A realist approach aims to provide causal explanations through the generation and articulation of contexts, mechanisms and outcomes. Our search of electronic databases was supplemented with Google and citation checking to locate grey literature including news items and workforce reports. Included documents were from the UK, Australia, Canada and the Americas—countries within which the paramedic role within primary care is well established. Results Our searches resulted in 205 included documents, from which data were extracted to produce context-mechanism-outcome configurations (CMOCs) within a final programme theory. Our results outline that paramedics are more likely to be effective in contributing to primary care workforces when they are supported to expand their existing role through formal education and clinical supervision. We also found that unless paramedics were fully integrated into primary care services, they did not experience the socialisation needed to build trusting relationships with patients or physicians. Indeed, for patients to accept paramedics in primary care, their role and its implications for their care should be outlined by a trusted source. Conclusions Our realist review highlights the complexity surrounding the introduction of paramedics into primary care roles. As well as offering an insight into understanding the paramedic professional identity, we also discuss the range of expectations this professional group will face in the transition to primary care. These expectations come from patients, general practitioners (family physicians) and paramedics themselves. This review is the first to offer insight into understanding the impact paramedics may have on the international primary care workforce and shaping how they might be optimally deployed.

BMJ Open ◽  
2021 ◽  
Vol 11 (3) ◽  
pp. e039809
Author(s):  
Sharon Dixon ◽  
Claire Duddy ◽  
Gabrielle Harrison ◽  
Chrysanthi Papoutsi ◽  
Sue Ziebland ◽  
...  

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.


BMJ Open ◽  
2021 ◽  
Vol 11 (6) ◽  
pp. e046078
Author(s):  
Amy Finlay-Jones ◽  
Jetro Emanel Ang ◽  
Elaine Bennett ◽  
Jenny Downs ◽  
Sally Kendall ◽  
...  

IntroductionSelf-regulation is a modifiable protective factor for lifespan mental and physical health outcomes. Early caregiver-mediated interventions to promote infant and child regulatory outcomes prevent long-term developmental, emotional and behavioural difficulties and improve outcomes such as school readiness, educational achievement and economic success. To harness the population health promise of these programmes, there is a need for more nuanced understanding of the impact of these interventions. The aim of this realist review is to understand how, why, under which circumstances and for whom, early caregiver-mediated interventions improve infant and child self-regulation. The research questions guiding this review were based on consultation with families and community organisations that provide early childhood and family services.Methods and analysisRealist reviews take a theory-driven and iterative approach to evidence synthesis, structured around continuous refinement of a programme theory. Programme theories specify context-mechanism-outcome configurations to explain what works, for whom, under which circumstances and how. Our initial programme theory is based on prior work in this field and will be refined through the review process. A working group, comprising service users, community organisation representatives, representatives from specific populations, clinicians and review team members will guide the evidence synthesis and interpretation, as well as the development and dissemination of recommendations based on the findings of the review. The review will involve searching: (i) electronic databases, (ii) connected papers, articles and citations and (iii) grey literature. Decisions to include evidence will be guided by judgements about their contribution to the programme theory and will be made by the research team, with input from the working group. Evidence synthesis will be reported using the Realist and MEta-narrative Evidence Synthesis: Evolving Standards guidelines.Ethics and disseminationEthical approval is not required as this is a review. Findings will be disseminated to our working group and through peer-reviewed publications and conference presentations.Review registration numberThe protocol is registered with Open Science Framework https://osf.io/5ce2z/registrations.


BMJ Open ◽  
2018 ◽  
Vol 8 (10) ◽  
pp. e025943 ◽  
Author(s):  
Tristan Price ◽  
Nicola Brennan ◽  
Jennifer Cleland ◽  
Linda Prescott-Clements ◽  
Amanda Wanner ◽  
...  

IntroductionUnderperformance by doctors poses a risk to patient safety. Remediation is an intervention designed to remedy underperformance and return a doctor to safe practice. Remediation is widely used across healthcare systems globally, and has clear implications for both patient safety and doctor retention. Yet, there is a poor evidence base to inform remediation programmes. In particular, there is a lack of understanding as to why and how a remedial intervention may work to change a doctor’s practice. The aim of this research is to identify why, how, in what contexts, for whom and to what extent remediation programmes for practising doctors work to support patient safety.Methods and analysisRealist review is an approach to evidence synthesis that seeks to develop programme theories about how an intervention works to produce its effects. The initial search strategy will involve: database and grey literature searching, citation searching and contacting authors. The evidence search will be extended as the review progresses and becomes more focused on the development of specific aspects of the programme theory. The development of the programme theory will involve input from a stakeholder group consisting of professional experts in the remediation process and patient representatives. Evidence synthesis will use a realist logic of analysis to interrogate data in order to develop and refine the initial programme theory into a more definitive realist programme theory of how remediation works. The study will follow and be reported according to Realist And Meta-narrative Evidence Syntheses—Evolving Standards (RAMESES).Ethics and disseminationEthical approval is not required. Our dissemination strategy will include input from our stakeholder group. Customised outputs will be developed using the knowledge-to-action cycle framework, and will be targeted to: policy-makers; education providers and regulators, the National Health Service, doctors and academics.PROSPERO registration numberCRD42018088779.


2019 ◽  
Vol 4 (3) ◽  
pp. 35-42 ◽  
Author(s):  
Georgette Eaton ◽  
Veronika Williams ◽  
Geoff Wong ◽  
Nia Roberts ◽  
Kamal R. Mahtani

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.


2019 ◽  
Vol 30 (4) ◽  
pp. 664-673 ◽  
Author(s):  
Julia V Pescheny ◽  
Gurch Randhawa ◽  
Yannis Pappas

Abstract Background Social prescribing initiatives are widely implemented in the UK National Health Service to integrate health and social care. Social prescribing is a service in primary care that links patients with non-medical needs to sources of support provided by the community and voluntary sector to help improve their health and wellbeing. Such programmes usually include navigators, who work with referred patients and issue onward referrals to sources of non-medical support. This systematic review aimed to assess the evidence of service user outcomes of social prescribing programmes based on primary care and involving navigators. Methods We searched 11 databases, the grey literature, and the reference lists of relevant studies to identify the available evidence on the impact of social prescribing on service users. Searches were limited to literature written in English. No date restrictions were applied, and searches were conducted to June 2018. Findings were synthesized narratively, employing thematic analysis. The Mixed Methods Appraisal Tool Version 2011 was used to evaluate the methodological quality of included studies. Results Sixteen studies met the inclusion criteria. The evidence base is mixed, some studies found improvements in health and wellbeing, health-related behaviours, self-concepts, feelings, social contacts and day-to-day functioning post-social prescribing, whereas others have not. The review also shows that the evaluation methodologies utilized were variable in quality. Conclusion In order to assess the success of social prescribing services, more high quality and comparable evaluations need to be conducted in the future. International Prospective Register of Systematic Reviews number: CRD42017079664


BMJ Open ◽  
2021 ◽  
Vol 11 (7) ◽  
pp. e050033
Author(s):  
Norina Gasteiger ◽  
Sabine N van der Veer ◽  
Paul Wilson ◽  
Dawn Dowding

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.


BMJ Open ◽  
2021 ◽  
Vol 11 (4) ◽  
pp. e043091
Author(s):  
Rikke Siersbaek ◽  
John Alexander Ford ◽  
Sara Burke ◽  
Clíona Ní Cheallaigh ◽  
Steve Thomas

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.


2019 ◽  
Vol 76 (Suppl 1) ◽  
pp. A34.3-A35
Author(s):  
Michael Di Donato ◽  
Ross Iles ◽  
Tyler Lane ◽  
Alex Collie

BackgroundLow back pain (LBP) is a leading cause of work disability. While absent from work, workers with LBP may receive income support from a system such as workers’ compensation or social security. Current evidence suggests that income support systems can influence recovery from LBP, but provides little evidence as to why and how these effects occur. This study examines how and in what contexts income support systems impact the healthcare quality and functional capacity of people with work disability and LBP.MethodsWe performed a realist review, a type of literature review that seeks to explain how social interventions and phenomena in certain contexts generate outcomes, rather than simply whether or not they do. Five initial theories about the mechanisms of the relationship were developed, tested, and refined by acquiring and synthesising academic literature from purposive and iterative electronic database searching. This process was supplemented by grey literature searching for policy documents and legislative summaries, and semi-structured interviews with experts in income support, healthcare, and LBP.ResultsIncome support systems influence healthcare quality through healthcare funding restrictions, healthcare provider administrative burden, and allowing an employer to select healthcare providers. Income support systems influence worker functional capacity through the level of participation and share of income support funding required of employers, and through certain administrative procedures. These mechanisms are often exclusively context-dependent, and generate differing and unintended outcomes depending on features of the healthcare and income support system, as well as other contextual factors such as socioeconomic status and labour force composition.ConclusionIncome support systems impact the healthcare quality and functional capacity of people with work disability and LBP through context-dependent financial control, regulatory, and administrative mechanisms. Future policy design and research efforts should consider how income support systems may indirectly influence workers with LBP via the workplace.


BMJ Open ◽  
2018 ◽  
Vol 8 (11) ◽  
pp. e024876 ◽  
Author(s):  
Ruth Abrams ◽  
Geoffrey Wong ◽  
Kamal Ram Mahtani ◽  
Stephanie Tierney ◽  
Anne-Marie Boylan ◽  
...  

IntroductionIn western countries, early visiting services (EVS) have been proposed as a recent intervention to reduce both general practitioner workload and hospital admissions among housebound individuals experiencing a healthcare need within the community. EVS involves the delegation of the patient home visits to other staff groups such as paramedics or nursing staff. However, the principles of organising this care are unknown and it remains unclear how different contexts, such as patient conditions and the processes of organising EVS influence care outcomes. A review has been designed to understand how EVS are enacted and, specifically, who benefits, why, how and when in order to provide further insight into the design and delivery of EVS.Methods and analysisThe purpose of this review is to produce findings that provide explanations of how and why EVS contexts influence their associated outcomes. Evidence on EVS will be consolidated through realist review—a theory-driven approach to evidence synthesis. A realist approach is needed as EVS is a complex intervention. What EVS achieve is likely to vary for different individuals and contexts. We expect to synthesise a range of relevant data such as qualitative, quantitative and mixed-method research in the following stages: devising an initial programme theory, searching evidence, selecting appropriate documents, extracting data, synthesising and refining the programme theory.Ethics and disseminationA formal ethics review is not required as this study is secondary research. Findings will be disseminated in a peer-reviewed journal, at national and international conferences and to relevant professional associations.PROSPERO registration numberCRD42018096518.


2019 ◽  
Vol 3 (Supplement_1) ◽  
pp. S765-S766
Author(s):  
Josea Kramer ◽  
Joe Douglas ◽  
Shawn Clarke ◽  
Luis Melendez

Abstract The VA has invested in developing the skills of its primary care workforce through the longitudinal Geriatric Scholars Program. The program consists of core components --- intensive course in geriatrics, intensive workshop in quality improvement (QI) and initiation of a micro QI projects in the Scholar’s clinic; electives allow learners to tailor the program to self-identified gaps in knowledge, skills and competencies. The program has demonstrated direct impacts of continuing education through a workforce development process that enhances skills and competencies at a pace and selection that meets clinicians’ self-identified gaps in training. Now in its 11th year, the program has been shown to increase career satisfaction and job retention, standardize provider behaviors, improve clinical decision-making and reduce dispensing of potentially inappropriate medications. This symposium further explores the impact of the program on individual clinicians and on clinical teams.


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