A realist analysis of hospital patient safety in Wales:Applied learning for alternative contexts from a multisite case study

Background: Hospital patient safety is a major social problem. In the UK, policy responses focus on the introduction of improvement programmes that seek to implement evidence-based clinical practices using the Model for Improvement, Plan-Do-Study-Act cycle. Empirical evidence that the outcomes of such programmes vary across hospitals demonstrates that the context of their implementation matters. However, the relationships between features of context and the implementation of safety programmes are both undertheorised and poorly understood in empirical terms. Objectives: This study is designed to address gaps in conceptual, methodological and empirical knowledge about the influence of context on the local implementation of patient safety programmes. Design: We used concepts from critical realism and institutional analysis to conduct a qualitative comparative-intensive case study involving 21 hospitals across all seven Welsh health boards. We focused on the local implementation of three focal interventions from the 1000 Lives+ patient safety programme: Improving Leadership for Quality Improvement, Reducing Surgical Complications and Reducing Health-care Associated Infection. Our main sources of data were 160 semistructured interviews, observation and 1700 health policy and organisational documents. These data were analysed using the realist approaches of abstraction, abduction and retroduction. Setting: Welsh Government and NHS Wales. Participants: Interviews were conducted with 160 participants including government policy leads, health managers and professionals, partner agencies with strategic oversight of patient safety, advocacy groups and academics with expertise in patient safety. Main outcome measures: Identification of the contextual factors pertinent to the local implementation of the 1000 Lives+ patient safety programme in Welsh NHS hospitals. Results: An innovative conceptual framework harnessing realist social theory and institutional theory was produced to address challenges identified within previous applications of realist inquiry in patient safety research. This involved the development and use of an explanatory intervention–context–mechanism–agency–outcome (I-CMAO) configuration to illustrate the processes behind implementation of a change programme. Our findings, illustrated by multiple nested I-CMAO configurations, show how local implementation of patient safety interventions are impacted and modified by particular aspects of context: specifically, isomorphism, by which an intervention becomes adapted to the environment in which it is implemented; institutional logics, the beliefs and values underpinning the intervention and its source, and their perceived legitimacy among different groups of health-care professionals; and the relational structure and power dynamics of the functional group, that is, those tasked with implementing the initiative. This dynamic interplay shapes and guides actions leading to the normalisation or the rejection of the patient safety programme. Conclusions: Heightened awareness of the influence of context on the local implementation of patient safety programmes is required to inform the design of such interventions and to ensure their effective implementation and operationalisation in the day-to-day practice of health-care teams. Future work is required to elaborate our conceptual model and findings in similar settings where different interventions are introduced, and in different settings where similar innovations are implemented. Funding: The National Institute for Health Research Health Services and Delivery Research programme

The Effect of Stress on Motor Function in <i>Drosophila</i>

<div><p>Exposure to unpredictable and uncontrollable conditions causes animals to perceive stress and change their behavior. It is unclear how the perception of stress modifies the motor components of behavior and which molecular pathways affect the behavioral change. In order to understand how stress affects motor function, we developed an experimental platform that quantifies walking motions in <i>Drosophila</i>. We found that stress induction using electrical shock results in backwards motions of the forelegs at the end of walking strides. These leg retrogressions persisted during repeated stimulation, although they habituated substantially. The motions also continued for several strides after the end of the shock, indicating that stress induces a behavioral aftereffect. Such aftereffect could also be induced by restricting the motion of the flies via wing suspension. Further, the long-term effects could be amplified by combining either immobilization or electric shock with additional stressors. Thus, retrogression is a lingering form of response to a broad range of stressful conditions, which cause the fly to search for a foothold when it faces extreme and unexpected challenges. Mutants in the cAMP signaling pathway enhanced the stress response, indicating that this pathway regulates the behavioral response to stress. Our findings identify the effect of stress on a specific motor component of behavior and define the role of cAMP signaling in this stress response.</p></div

Effects of combining amputation and suspension on fly walking.

<p><b>A</b>. Retrogression at different times after release from suspension. Amputated and suspended flies display a robust increase in backtracking that gradually decreases. Recovery of retrogression was fit to a monoexponential decay with a time constant of 11±2 min. n = 15. * p<0.05, Wilcoxon signed-rank test. <b>B</b>. Onset time course of walking adaptations. Flies were suspended for increasing durations and the retrogression was determined upon release at each time point. Data were fit to a monoexponential association with a time constant of 10 min. n≥10. p = 0.0025, Kruskal-Wallis test. * p<0.05 ** p<0.01, Mann-Whitney test with Bonferroni correction for multiple comparisons. <b>C</b>. Habituation of the response to combined amputation and suspension. The initial response upon release from suspension (blue) decreases to the baseline level of flies that have recovered from stress (red). p<0.05, Friedman test. * p<0.05, Wilcoxon signed rank test with bonferroni correction of p values. <b>D</b>. Sustained retrogressions could be repeatedly toggled. Retrogression at 0 min (red bars) and 30 min (blue bars) after two consecutive two hour suspension treatments (Susp1 and Susp2). n = 19–21. p = 0.0009, Friedman test. ** p<0.01 * p<0.05, Wilcoxon signed-rank test. Error bars are mean ±SEM.</p

Effects of leg tip amputation on fly walking.

<p><b>A</b>. Leg trajectories immediately after amputation of front left leg (0 min) and after 2 hours of recovery (120 min). Black dots are touchdowns. Blue lines represent forward motions in the amputated leg, while red lines represent retrogression. <b>B</b>. Retrogression at different times after amputation. Note that the retrogression following amputation (initial vs. final value) is not statistically significant. The inset is a schematic of the amputated front leg showing the amputated section in black shading. n = 17. <b>C</b>. Slippery surfaces amplify the effects of electric shock. Δ retrogression is the difference between retrogression during the first four steps of recovery from electric shock and retrogression prior to the electric shock, and controls for changes in baseline retrogression between the three conditions tested. n = 12–17. p = 0.0033, Kruskal-wallis test. * p<0.05, ** p<0.01, Mann-Whitney test with bonferroni correction of p values. Error bars are mean ±SEM.</p

Walking analysis parameters.

<p>The table lists the parameters that are calculated from the frame-by-frame acquisition of coordinates. Reference appears whenever a parameter has been used before.</p><p>Walking analysis parameters.</p