A realist synthesis of educational outreach visiting and integrated academic detailing to influence prescribing in ambulatory care: why relationships and dialogue matter

Background Many quality improvement initiatives in healthcare employ educational outreach visits, integrating academic detailing to bridge evidence-practice gaps and accelerate knowledge translation. Replicability of their outcomes in different contexts varies, and what makes some visiting programmes more successful than others is unclear. Objective We conducted a realist synthesis to develop theories of what makes educational outreach visiting integrating academic detailing work, for whom, under which circumstances and why, focusing on the clinician-visitor interaction when influencing prescribing of medicines in ambulatory care settings. Methods The realist review was performed in accordance with RAMESES standards. An initial programme theory was generated, academic databases and grey literature were screened for documents with detail on contexts, intervention and outcomes. Using realist logic of analysis, data from 43 documents were synthesised in the generation of a refined programme theory, supported by additional theoretical frameworks of learning and communication. Results Twenty-seven interdependent context-mechanism-outcome configurations explain how clinicians engage with educational outreach visits integrating academic detailing through programme design, what matters in programme design and the educational visitor-clinician interaction and how influence extends beyond the visit. They suggest that in addition to relevance, credibility and trustworthiness of a visit’s contents, communication and clinical skills of educational visitors, the relationship between the educational visitor and clinician, built on a dialogue of learning from and sense-making with each other, creates conditions of critical thinking which are conducive to facilitating prescribing practice change when necessary. Conclusion This realist synthesis elucidates that the quality of clinician-educational visitor interactions is pivotal to educational outreach visiting programmes. Building and sustaining relationships, and establishing an open dialogue are important; neglecting these undermines the impact of visits. Educational visitors can facilitate clinicians’ reflection on practice and influence their prescribing. Clinicians value the discussion of individualised, tailored information and advice they can translate into their practice. PROSPERO registration number CRD42021258199

Understanding how and why quality circles improve standards of practice, enhance professional development and increase psychological well-being of general practitioners: a realist synthesis.

OBJECTIVES To understand how and why participation in quality circles (QCs) improves general practitioners' (GPs) psychological well-being and the quality of their clinical practice. To provide evidence-informed and practical guidance to maintain QCs at local and policy levels. DESIGN A theory-driven mixed method. SETTING Primary healthcare. METHOD We collected data in four stages to develop and refine the programme theory of QCs: (1) coinquiry with Swiss and European expert stakeholders to develop a preliminary programme theory; (2) realist review with systematic searches in MEDLINE, Embase, PsycINFO and CINHAL (1980-2020) to inform the preliminary programme theory; (3) programme refinement through interviews with participants, facilitators, tutors and managers of QCs and (4) consolidation of theory through interviews with QC experts across Europe and examining existing theories. SOURCES OF DATA The coinquiry comprised 4 interviews and 3 focus groups with 50 European experts. From the literature search, we included 108 papers to develop the literature-based programme theory. In stage 3, we used data from 40 participants gathered in 6 interviews and 2 focus groups to refine the programme theory. In stage 4, five interviewees from different healthcare systems consolidated our programme theory. RESULT Requirements for successful QCs are governmental trust in GPs' abilities to deliver quality improvement, training, access to educational material and performance data, protected time and financial resources. Group dynamics strongly influence success; facilitators should ensure participants exchange knowledge and generate new concepts in a safe environment. Peer interaction promotes professional development and psychological well-being. With repetition, participants gain confidence to put their new concepts into practice. CONCLUSION With expert facilitation, clinical review and practice opportunities, QCs can improve the quality of standard practice, enhance professional development and increase psychological well-being in the context of adequate professional and administrative support. PROSPERO REGISTRATION NUMBER CRD42013004826

Supporting bereavement and complicated grief in primary care: a realist review.

BACKGROUND: Bereavement can have significant impacts on physical and mental health, and a minority of people experience complicated and prolonged grief responses. Primary care is ideally situated to offer bereavement care, yet UK provision remains variable and practitioners feel uncertain how best to support bereaved patients. AIM: To identify what works, how, and for whom, in the management of complicated grief (CG) in primary care. DESIGN & SETTING: A review of evidence on the management of CG and bereavement in UK primary care settings. METHOD: A realist approach was taken that aims to provide causal explanations through the generation and articulation of contexts, mechanisms, and outcomes. RESULTS: Forty-two articles were included. Evidence on the primary care management of complicated or prolonged grief was limited. GPs and nurses view bereavement support as part of their role, yet experience uncertainty over the appropriate extent of their involvement. Patients and clinicians often have differing views on the role of primary care in bereavement. Training in bereavement, local systems for reporting deaths, practitioner time, and resources can assist or hinder bereavement care provision. Practitioners find bereavement care can be emotionally challenging. Understanding patients' needs can encourage a proactive response and help identify appropriate support. CONCLUSION: Bereavement care in primary care remains variable and practitioners feel unprepared to provide appropriate bereavement care. Patients at higher risk of complicated or prolonged grief may fail to receive the support they need from primary care. Further research is required to address the potential unmet needs of bereaved patients

Protocol - realist and meta-narrative evidence synthesis: Evolving Standards (RAMESES)

<p>Abstract</p> <p>Background</p> <p>There is growing interest in theory-driven, qualitative and mixed-method approaches to systematic review as an alternative to (or to extend and supplement) conventional Cochrane-style reviews. These approaches offer the potential to expand the knowledge base in policy-relevant areas - for example by explaining the success, failure or mixed fortunes of complex interventions. However, the quality of such reviews can be difficult to assess. This study aims to produce methodological guidance, publication standards and training resources for those seeking to use the realist and/or meta-narrative approach to systematic review.</p> <p>Methods/design</p> <p>We will: [a] collate and summarise existing literature on the principles of good practice in realist and meta-narrative systematic review; [b] consider the extent to which these principles have been followed by published and in-progress reviews, thereby identifying how rigour may be lost and how existing methods could be improved; [c] using an online Delphi method with an interdisciplinary panel of experts from academia and policy, produce a draft set of methodological steps and publication standards; [d] produce training materials with learning outcomes linked to these steps; [e] pilot these standards and training materials prospectively on real reviews-in-progress, capturing methodological and other challenges as they arise; [f] synthesise expert input, evidence review and real-time problem analysis into more definitive guidance and standards; [g] disseminate outputs to audiences in academia and policy. The outputs of the study will be threefold:</p> <p>1. Quality standards and methodological guidance for realist and meta-narrative reviews for use by researchers, research sponsors, students and supervisors</p> <p>2. A 'RAMESES' (Realist and Meta-review Evidence Synthesis: Evolving Standards) statement (comparable to CONSORT or PRISMA) of publication standards for such reviews, published in an open-access academic journal.</p> <p>3. A training module for researchers, including learning outcomes, outline course materials and assessment criteria.</p> <p>Discussion</p> <p>Realist and meta-narrative review are relatively new approaches to systematic review whose overall place in the secondary research toolkit is not yet fully established. As with all secondary research methods, guidance on quality assurance and uniform reporting is an important step towards improving quality and consistency of studies.</p

Understanding how appraisal of doctors produces its effects: a realist review protocol

INTRODUCTION: UK doctors are now required to participate in revalidation to maintain their licence to practise. Appraisal is a fundamental component of revalidation. However, objective evidence of appraisal changing doctors' behaviour and directly resulting in improved patient care is limited. In particular, it is not clear how the process of appraisal is supposed to change doctors' behaviour and improve clinical performance. The aim of this research is to understand how and why appraisal of doctors is supposed to produce its effect. METHODS AND ANALYSIS: Realist review is a theory-driven interpretive approach to evidence synthesis. It applies realist logic of inquiry to produce an explanatory analysis of an intervention that is, what works, for whom, in what circumstances, in what respects. Using a realist review approach, an initial programme theory of appraisal will be developed by consulting with key stakeholders in doctors' appraisal in expert panels (ethical approval is not required), and by searching the literature to identify relevant existing theories. The search strategy will have a number of phases including a combination of: (1) electronic database searching, for example, EMBASE, MEDLINE, the Cochrane Library, ASSIA, (2) 'cited by' articles search, (3) citation searching, (4) contacting authors and (5) grey literature searching. The search for evidence will be iteratively extended and refocused as the review progresses. Studies will be included based on their ability to provide data that enable testing of the programme theory. Data extraction will be conducted, for example, by note taking and annotation at different review stages as is consistent with the realist approach. The evidence will be synthesised using realist logic to interrogate the final programme theory of the impact of appraisal on doctors' performance. The synthesis results will be written up according to RAMESES guidelines and disseminated through peer-reviewed publication and presentations. TRIAL REGISTRATION NUMBER: The protocol is registered with PROSPERO 2014:CRD42014007092.UK Department of HealthNational Institute for Health Research (NIHR

The person-based development and realist evaluation of a summary report for GP consultations

Background: Use of telephone, video and e-consultations is increasing. These can make consultations more transactional. This study aimed to develop a complex intervention to address patients’ concerns more comprehensively in general practice and test the feasibility of this in a cluster-randomised framework. The complex intervention used two technologies: a patient-completed pre-consultation form used at consultation opening and a doctor-provided summary report provided at consultation closure. This paper reports on the development and realist evaluation of the summary report. Methods: A person-based approach was used to develop the summary report. An electronic protocol was designed to automatically generate the report after GPs complete a clinical template in the patient record. This was tested with 45 patients in 3 rounds each, with iterative adjustments made based on feedback after each round. Subsequently, an intervention incorporating the pre-consultation form with the summary report was then tested in a cluster-randomised framework with 30 patients per practice in six practices: four randomised to intervention, and two to control. An embedded realist evaluation was carried out. The main feasibility study results are reported elsewhere. Results: Intervention Development: 15 patients were recruited per practice. Eight patients and six GPs were interviewed and 18 changes made. The summary report improved substantially; GPs and patients in the final practice were more satisfied with the report than the first practice. Realist evaluation: The summary was most useful for consultations when safety-netting advice was important or with multiple complex follow-up steps in patients who have difficulty remembering or communicating. It generated greater clarity on the follow-up and greater patient empowerment and reassurance. Conclusions: The person-based approach was successful. The summary report creates clarity, empowerment and reassurance in certain consultations and patients. As it takes a few minutes per patient, GPs prefer to select patients who will benefit most

Case reports: A helping hand to generalists

Clinical decision making can be challenging for both generalists and specialists. Case reports may assist the decision making process either by providing guidance to generalists on identifying rarer conditions or a searchable database for looking up seemingly disparate symptoms. This editorial highlights the innovations being implemented by Journal of Medical Case Reports and Cases Journal in developing an educational resource to help clinicians in decision-making

Interventions to minimise doctors’ mental ill-health and its impacts on the workforce and patient care: the Care Under Pressure realist review

BackgroundThe growing incidence of mental ill-health in health professionals, including doctors, is a global concern. Although a large body of literature exists on interventions that offer support, advice and/or treatment to sick doctors, it has not yet been synthesised in a way that takes account of the complexity and heterogeneity of the interventions, and the many dimensions (e.g. individual, organisational, sociocultural) of the problem.ObjectivesOur aim was to improve understanding of how, why and in what contexts mental health services and support interventions can be designed to minimise the incidence of doctors’ mental ill-health. The objectives were to review interventions to tackle doctors’ mental ill-health and its impact on the clinical workforce and patient care, drawing on diverse literature sources and engaging iteratively with diverse stakeholder perspectives to produce actionable theory; and recommendations that support the tailoring, implementation, monitoring and evaluation of contextually sensitive strategies to tackle mental ill-health and its impacts.DesignRealist literature review consistent with the Realist And Meta-narrative Evidence Syntheses: Evolving Standards quality and reporting standards.Data sourcesBibliographic database searches were developed and conducted using MEDLINE (1946 to November week 4 2017), MEDLINE In-Process and Other Non-indexed Citations (1946 to 6 December 2017) and PsycINFO (1806 to November week 2 2017) (all via Ovid) and Applied Social Sciences Index and Abstracts (1987 to 6 December 2017) (via ProQuest) on 6 December 2017. Further UK-based studies were identified by forwards and author citation searches, manual backwards citation searching and hand-searching relevant journal websites.Review methodsWe included all studies that focused on mental ill-health; all study designs; all health-care settings; all studies that included medical doctors/medical students; descriptions of interventions or resources that focus on improving mental ill-health and minimising its impacts; all mental health outcome measures, including absenteeism (doctors taking short-/long-term sick leave); presenteeism (doctors working despite being unwell); and workforce retention (doctors leaving the profession temporarily/permanently). Data were extracted from included articles and the data set was subjected to realist analysis to identify context–mechanism–outcome configurations.ResultsA total of 179 out of 3069 records were included. Most were from the USA (45%) and had been published since 2009 (74%). More included articles focused on structural-level interventions (33%) than individual-level interventions (21%), but most articles (46%) considered both levels. Most interventions focused on prevention, rather than treatment/screening, and most studies referred to doctors/physicians in general, rather than to specific specialties or career stages. Nineteen per cent of the included sources provided cost information and none reported a health economic analysis. The 19 context–mechanism–outcome configurations demonstrated that doctors were more likely to experience mental ill-health when they felt isolated or unable to do their job, and when they feared repercussions of help-seeking. Healthy staff were necessary for excellent patient care. Interventions emphasising relationships and belonging were more likely to promote well-being. Interventions creating a people-focused working culture, balancing positive/negative performance and acknowledging positive/negative aspects of a medical career helped doctors to thrive. The way that interventions were implemented seemed critically important. Doctors needed to have confidence in an intervention for the intervention to be effective.LimitationsVariable quality of included literature; limited UK-based studies.Future workUse this evidence synthesis to refine, implement and evaluate interventions

Optimising strategies to address mental ill-health in doctors and medical students: 'Care under Pressure' realist review and implementation guidance

© 2020 The Author(s). Background: Mental ill-health in health professionals, including doctors, is a global and growing concern. The existing literature on interventions that offer support, advice and/or treatment to sick doctors has not yet been synthesised in a way that considers the complexity and heterogeneity of the interventions, and the many dimensions of the problem. We (1) reviewed interventions to tackle doctors' and medical students' mental ill-health and its impacts on the clinical workforce and patient care - drawing on diverse literature sources and engaging iteratively with diverse stakeholder perspectives - and (2) produced recommendations that support the tailoring, implementation, monitoring and evaluation of contextually sensitive strategies to tackle mental ill-health and its impacts. Methods: Realist literature review consistent with the RAMESES quality and reporting standards. Sources for inclusion were identified through bibliographic database searches supplemented by purposive searches - resulting also from engagement with stakeholders. Data were extracted from included articles and subjected to realist analysis to identify (i) mechanisms causing mental ill-health in doctors and medical students and relevant contexts or circumstances when these mechanisms were likely to be 'triggered' and (ii) 'guiding principles' and features underpinning the interventions and recommendations discussed mostly in policy document, reviews and commentaries. Results: One hundred seventy-nine records were included. Most were from the USA (45%) and were published since 2009 (74%). The analysis showed that doctors were more likely to experience mental ill-health when they felt isolated or unable to do their job and when they feared repercussions of help-seeking. Healthy staff were necessary for excellent patient care. Interventions emphasising relationships and belonging were more likely to promote wellbeing. Interventions creating a people-focussed working culture, balancing positive/negative performance and acknowledging positive/negative aspects of a medical career helped doctors to thrive. The way that interventions were implemented seemed critically important. Doctors and medical students needed to have confidence in an intervention for the intervention to be effective. Conclusions: Successful interventions to tackle doctors' and students' mental ill-health are likely to be multidimensional and multilevel and involve multiple stakeholders. Evaluating and improving existing interventions is likely to be more effective than developing new ones. Our evidence synthesis provides a basis on which to do this. Study registration: PROSPERO CRD42017069870. Research project webpage http://sites.exeter.ac.uk/cup