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

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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Understanding the impact of delegated home visiting services accessed via general practice by community-dwelling patients: a realist review protocol

BMJ Open ◽

10.1136/bmjopen-2018-024876 ◽

2018 ◽

Vol 8 (11) ◽

pp. e024876 ◽

Cited By ~ 7

Author(s):

Ruth Abrams ◽

Geoffrey Wong ◽

Kamal Ram Mahtani ◽

Stephanie Tierney ◽

Anne-Marie Boylan ◽

...

Keyword(s):

Home Visiting ◽

Hospital Admissions ◽

Evidence Synthesis ◽

Realist Review ◽

Professional Associations ◽

Community Dwelling ◽

Mixed Method Research ◽

Programme Theory ◽

Registration Number ◽

The Impact

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.

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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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Caregiver-mediated interventions to support self-regulation among infants and young children (0–5 years): a protocol for a realist review

BMJ Open ◽

10.1136/bmjopen-2020-046078 ◽

2021 ◽

Vol 11 (6) ◽

pp. e046078

Author(s):

Amy Finlay-Jones ◽

Jetro Emanel Ang ◽

Elaine Bennett ◽

Jenny Downs ◽

Sally Kendall ◽

...

Keyword(s):

School Readiness ◽

Working Group ◽

Protective Factor ◽

Evidence Synthesis ◽

Grey Literature ◽

Self Regulation ◽

Realist Review ◽

Programme Theory ◽

Review Team ◽

The Impact

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.

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

BMC Medicine ◽

10.1186/s12916-021-02019-z ◽

2021 ◽

Vol 19 (1) ◽

Author(s):

Georgette Eaton ◽

Geoff Wong ◽

Stephanie Tierney ◽

Nia Roberts ◽

Veronika Williams ◽

...

Keyword(s):

Primary Care ◽

Clinical Supervision ◽

Formal Education ◽

Grey Literature ◽

Realist Review ◽

Evidence Base ◽

Programme Theory ◽

Primary Care Workforce ◽

The Impact ◽

Insight Into

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.

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

BMJ Open ◽

10.1136/bmjopen-2020-045822 ◽

2021 ◽

Vol 11 (9) ◽

pp. e045822

Author(s):

Lynn V Monrouxe ◽

Peter Hockey ◽

Priya Khanna ◽

Christiane Klinner ◽

Lise Mogensen ◽

...

Keyword(s):

Medical Students ◽

Success Factors ◽

Realist Review ◽

Physician Assistants ◽

Realist Evaluation ◽

Health Practitioner ◽

Local Health ◽

Medical Council ◽

Programme Theory ◽

Quantitative Evidence

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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Sedation/Analgesia Administration Practice Varies according to Endoscopy Facility (Hospital- or Office-Based) Setting: Results from a Nationwide Survey in Greece

Gastroenterology Research and Practice ◽

10.1155/2020/8701791 ◽

2020 ◽

Vol 2020 ◽

pp. 1-9

Author(s):

Georgios Tziatzios ◽

Dimitrios N. Samonakis ◽

Theocharis Tsionis ◽

Spyridon Goulas ◽

Dimitrios Christodoulou ◽

...

Keyword(s):

Airway Management ◽

Public Hospital ◽

Private Hospital ◽

Life Support ◽

Advanced Life Support ◽

Nationwide Survey ◽

Web Based ◽

The Public ◽

Management Techniques ◽

The Impact

Objectives. To examine the impact of endoscopy setting (hospital-based vs. office-based) on sedation/analgesia administration and to provide nationwide data on monitoring practices among Greek gastroenterologists in real-world settings. Material and Methods. A web-based survey regarding sedation/analgesia rates and monitoring practices during endoscopy either in a hospital-based or in an office-based setting was disseminated to the members of the Hellenic Society of Gastroenterology and Professional Association of Gastroenterologists. Participants were asked to complete a questionnaire, which consisted of 35 items, stratified into 4 sections: demographics, preprocedure (informed consent, initial patient evaluation), intraprocedure (monitoring practices, sedative agents’ administration rate), and postprocedure practices (recovery). Results. 211 individuals responded (response rate: 40.3%). Propofol use was significantly higher in the private hospital compared to the public hospital and the office-based setting for esophagogastroduodenoscopy (EGD) (85.8% vs. 19.5% vs. 10.5%, p<0.0001) and colonoscopy (88.2% vs. 20.1% vs. 9.4%, p<0.0001). This effect was not detected for midazolam, pethidine, and fentanyl use. Endoscopists themselves administered the medications in most cases. However, a significant contribution of anesthesiology sedation/analgesia provision was detected in private hospitals (14.7% vs. 2.8% vs. 2.4%, p<0.001) compared to the other settings. Only 35.2% of the private offices have a separate recovery room, compared to 80.4% and 58.7% of the private hospital- and public hospital-based facilities, respectively, while the nursing personnel monitored patients’ recovery in most of the cases. Participants were familiar with airway management techniques (83.9% with bag valve mask and 23.2% with endotracheal intubation), while 49.7% and 21.8% had received Basic Life Support (BLS) and Advanced Life Support (ALS) training, respectively. Conclusion. The private hospital-based setting is associated with higher propofol sedation administration both for EGD and for colonoscopy. Greek endoscopists are adequately trained in airway management techniques.

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Towards an understanding of GPs’ viewpoint on diagnosing postnatal depression in general practice: a small-scale realist evaluation

Primary Health Care Research & Development ◽

10.1017/s1463423620000316 ◽

2020 ◽

Vol 21 ◽

Author(s):

Ashvanthi Nadira Sriranjan ◽

Ruth Abrams ◽

Geoff Wong ◽

Sophie Park

Keyword(s):

Primary Care ◽

Postnatal Depression ◽

Realist Evaluation ◽

Small Scale ◽

Thought Processes ◽

Programme Theory ◽

Self Reflection ◽

Assessment Guidelines ◽

Case Vignettes ◽

Diagnostic Approaches

Abstract Background: Less than half of postnatal depression cases are identified in routine clinical assessment. Guidelines and current literature suggest that general practitioners (GPs) may have an opportunistic role in detecting postnatal depression due to their early contact and existing rapport with many new mothers. There is limited research on the diagnostic approaches chosen by GPs in different GP−patient contexts. Our small-scale study evaluates the thought processes of seven GPs based in one practice when forming a clinical diagnosis of postnatal depression under different contexts. Methods: Seven GP participants were interviewed using case vignettes about postnatal depression, based on an adapted Johari’s window framework. A realist approach to analysis was undertaken with the intention of understanding GPs’ responses to different situations. Context−mechanism−outcome configurations were constructed, and a programme theory was formed to consolidate the findings. Findings: Findings suggest that diagnoses may be a clinician-led or collaborative process between GP and patient. In collaborative contexts, stigmatising views were addressed by GPs, time for self-reflection was encouraged and mothers’ views were accounted for. Clinician-led diagnoses often occurred in contexts where there was a lack of acknowledgement of symptoms on behalf of the patient or where safety was a concern. The personal and clinical experience of GPs themselves, as well as effective communication channels with other primary care professionals, was significant mechanisms. Conclusion: GPs use a variety of strategies to support patient disclosure and acceptance of their condition. The complexity of GP−patient contexts may influence the clinical thought process. We address some of the gaps in existing literature by exploring postnatal depression diagnosis in primary care and provide tentative explanations to suggest what works, for whom and in what contexts.

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Methodology of Specialist Physicians Training: From Traditional to e-Learning

International Journal of Environmental Research and Public Health ◽

10.3390/ijerph17207681 ◽

2020 ◽

Vol 17 (20) ◽

pp. 7681

Author(s):

Juan Chaves ◽

Antonio A. Lorca-Marín ◽

Emilio José Delgado-Algarra

Keyword(s):

Life Support ◽

Medical Training ◽

Advanced Life Support ◽

Sample Volume ◽

Mixed Methodology ◽

Face To Face ◽

Significant Difference ◽

The Face ◽

E Learning ◽

The Impact

Different studies show that mixed methodology can be effective in medical training. However, there are no conclusive studies in specialist training on advanced life support (ALS). The main objective of this research is to determine if, with mixed didactic methodology, which includes e-learning, similar results are produced to face-to-face training. The method used was quasi-experimental with a focus on efficiency and evaluation at seven months, in which 114 specialist doctors participated and where the analysis of the sociodemographic and pre-test variables points to the homogeneity of the groups. The intervention consisted of e-learning training plus face-to-face workshops versus standard. The results were the performance in knowledge and technical skills in cardiac arrest scenarios, the perceived quality, and the perception of the training. There were no significant differences in immediate or deferred performance. In the degree of satisfaction, a significant difference was obtained in favour of the face-to-face group. The perception in the training itself presented similar results. The main limitations consisted of sample volume, dropping out of the deferred tests, and not evaluating the transfer or the impact. Finally, mixed methodology including e-learning in ALS courses reduced the duration of the face-to-face sessions and allowed a similar performance.

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