The influence of contextual factors on healthcare quality improvement initiatives:a realist review

Background Recognising the influence of context and the context-sensitive nature of quality improvement (QI) interventions is crucial to implementing effective improvements and successfully replicating them in new settings, yet context is still poorly understood. To address this challenge, it is necessary to capture generalisable knowledge, first to understand which aspects of context are most important to QI and why, and secondly, to explore how these factors can be managed to support healthcare improvement, in terms of implementing successful improvement initiatives, achieving sustainability and scaling interventions. The research question was how and why does context influence quality improvement initiatives in healthcare? Methods A realist review explored the contextual conditions that influence healthcare improvement. Realist methodology integrates theoretical understanding and stakeholder input with empirical research findings. The review aimed to identify and understand the role of context during the improvement cycle, i.e. planning, implementation, sustainability and transferability; and distil new knowledge to inform the design and development of context-sensitive QI initiatives. We developed a preliminary theory of the influence of context to arrive at a conceptual and theoretical framework. Results Thirty-five studies were included in the review, demonstrating the interaction of key contextual factors across healthcare system levels during the improvement cycle. An evidence-based explanatory theoretical model is proposed to illustrate the interaction between contextual factors, system levels (macro, meso, micro) and the stages of the improvement journey. Findings indicate that the consideration of these contextual factors would enhance the design and delivery of improvement initiatives, across a range of improvement settings. Conclusions This is the first realist review of context in QI and contributes to a deeper understanding of how context influences quality improvement initiatives. The distillation of key contextual factors offers the potential to inform the design and development of context-sensitive interventions to enhance improvement initiatives and address the challenge of spread and sustainability. Future research should explore the application of our conceptual model to enhance improvement-planning processes

The production of subject-verb agreement among Swedish and Chinese second language speakers of English

This study uses a sentence completion task with Swedish and Chinese L2 English speakers to investigate how L1 morphosyntax and L2 proficiency influence L2 English subject-verb agreement production. Chinese has limited nominal and verbal number morphology, while Swedish has robust noun phrase (NP) morphology but does not number-mark verbs. Results showed that like L1 English speakers, both L2 groups used grammatical and conceptual number to produce subject-verb agreement. However, only L1 Chinese speakers—and less-proficient speakers in both L2 groups—were similarly influenced by grammatical and conceptual number when producing the subject NP. These findings demonstrate how L2 proficiency, perhaps combined with cross-linguistic differences, influence L2 production and underscore that encoding of noun and verb number are not independent