A realistic evaluation : the case of protocol-based care

Background 'Protocol based care' was envisioned by policy makers as a mechanism for delivering on the service improvement agenda in England. Realistic evaluation is an increasingly popular approach, but few published examples exist, particularly in implementation research. To fill this gap, within this paper we describe the application of a realistic evaluation approach to the study of protocol-based care, whilst sharing findings of relevance about standardising care through the use of protocols, guidelines, and pathways. Methods Situated between positivism and relativism, realistic evaluation is concerned with the identification of underlying causal mechanisms, how they work, and under what conditions. Fundamentally it focuses attention on finding out what works, for whom, how, and in what circumstances. Results In this research, we were interested in understanding the relationships between the type and nature of particular approaches to protocol-based care (mechanisms), within different clinical settings (context), and what impacts this resulted in (outcomes). An evidence review using the principles of realist synthesis resulted in a number of propositions, i.e., context, mechanism, and outcome threads (CMOs). These propositions were then 'tested' through multiple case studies, using multiple methods including non-participant observation, interviews, and document analysis through an iterative analysis process. The initial propositions (conjectured CMOs) only partially corresponded to the findings that emerged during analysis. From the iterative analysis process of scrutinising mechanisms, context, and outcomes we were able to draw out some theoretically generalisable features about what works, for whom, how, and what circumstances in relation to the use of standardised care approaches (refined CMOs). Conclusions As one of the first studies to apply realistic evaluation in implementation research, it was a good fit, particularly given the growing emphasis on understanding how context influences evidence-based practice. The strengths and limitations of the approach are considered, including how to operationalise it and some of the challenges. This approach provided a useful interpretive framework with which to make sense of the multiple factors that were simultaneously at play and being observed through various data sources, and for developing explanatory theory about using standardised care approaches in practice

The systematic position of Plagiochila moritziana, P. trichostoma and P. deflexa based on ITS sequence variation of nuclear ribosomal DNA, morphology, and lipophilic secondary metabolites

According to phylogenetic analyses of nrDNA ITS1 and ITS2 sequences (including the 5.8S unit) the Neotropical Plagiochila moritziana, P. rutilans var. rutilans, P. rutilans var. standleyi, P. trichostoma (= P. permista, syn. nov.), and P. subtrinitensis form a monophyletic lineage and are placed in P. sect. Rutilantes; all five taxa lack a ca 20 base pair sequence that is present in all the taxa of the other Plagiochila sections investigated. The Central American P. subtrinitensis is treated as a synonym of the Hawaiian endemic P. deflexa. Plagiochila moritziana is excluded from sect. Fuscoluteae and reduced to a variety of P. rutilans; P. sect. Permistae is treated as a synonym of P. sect. Rutilantes. The sporophytes of P. trichostoma and P. deflexa are described for the first time. Fresh material of P. rutilans var. moritziana exhibits a distinct odor of peppermint caused by the presence of several menthane monoterpenoids, principally pulegone. The Central American P. rutilans var. standleyi is reported from Ecuador, new to South America. Lectotypes are designated for P. rutilans var. moritziana, P. subtrinitensis, and P. trichostoma

A case study evaluation of implementation of a care pathway to support normal birth in one English birth centre: anticipated benefits and unintended consequences

Background: The policy drive for the UK National Health Service (NHS) has focused on the need for high quality services informed by evidence of best practice. The introduction of care pathways and protocols to standardise care and support implementation of evidence into practice has taken place across the NHS with limited evaluation of their impact. A multi-site case study evaluation was undertaken to assess the impact of use of care pathways and protocols on clinicians, service users and service delivery. One of the five sites was a midwifery-led Birth Centre, where an adapted version of the All Wales Clinical Pathway for Normal Birth had been implemented. Methods: The overarching framework was realistic evaluation. A case study design enabled the capture of data on use of the pathway in the clinical setting, use of multiple methods of data collection and opportunity to study and understand the experiences of clinicians and service users whose care was informed by the pathway. Women attending the Birth Centre were recruited at their 36 week antenatal visit. Episodes of care during labour were observed, following which the woman and the midwife who cared for her were interviewed about use of the pathway. Interviews were also held with other key stakeholders from the study site. Qualitative data were content analysed. Results: Observations were undertaken of four women during labour. Eighteen interviews were conducted with clinicians and women, including the women whose care was observed and the midwives who cared for them, senior midwifery managers and obstetricians. The implementation of the pathway resulted in a number of anticipated benefits, including increased midwifery confidence in skills to support normal birth and promotion of team working. There were also unintended consequences, including concerns about a lack of documentation of labour care and negative impact on working relationships with obstetric and other midwifery colleagues. Women were unaware their care was informed by a care pathway. Conclusion: Care pathways are complex interventions which generate a number of consequences for practice. Those considering introduction of pathways need to ensure all relevant stakeholders are engaged with this and develop robust evaluation strategies to accompany implementation

Making authentic: exploring boundary objects and bricolage in knowledge mobilisation through National Health Service-university partnerships

Background: In healthcare, bridging the research-to-practice gap is a top priority. Knowledge mobilisation scholars suggest that this gap can be closed through collaboration between knowledge users and producers. The concept of boundary objects – shared things and ideas that enable communication – has gained popularity across various collaborative work practices, but their potential within knowledge mobilisation in health care is understudied. An ongoing challenge for designers of boundary objects is how to create objects that are valued and shared both in principle and in practice. Aims and objectives: This paper reports on a study of boundary objects used during knowledge mobilisation through NHS-university partnerships called Collaborations for Leadership in Applied Health Research and Care (CLAHRCs). The distinction is investigated between boundary objects-in-theory and boundary objects-in-use, considering whether the latter possess specific characteristics which make them more effective during knowledge mobilisation. Methods: A qualitative case study of three CLAHRCs was conducted. Twenty-one people employed as ‘boundary spanners’ were interviewed to explore whether boundary objects played a role in knowledge mobilisation. Findings: The most effective boundary objects-in-use were co-produced through a process of bricolage. These possessed high levels of meaningfulness and resonance, and reconciled multiple user perspectives. Together these properties contributed to the overall authenticity of boundary objects-in-use. Discussion and conclusion: This paper helps to explain why designated boundary objects frequently fail in practice, and why there is a need to focus on understanding boundary objects based on symbolic, rather than structural, dimensions

How to Win Jobs and Influence Interviewers: A Psychological Exploration of Job Interview Best Practices

Navigating the formal employment interview has long been an imposing obstacle to acquiring gainful employment in the white-collar world, particularly that of the United States. Conventional wisdom offers a wide variety of suggestions for achieving the best possible outcomes from the interview, for instance smiling, having a firm handshake, demonstrating interest in the company, and “being yourself.” Much of this common knowledge is based primarily in intuition and carry-over from standard conversational best practices, rather than rigorous empirical testing. As such, this literature review sets out to bring together the various works of interview research that currently exist, with the goal of determining A) what candidate behaviors are most conducive to high interview ratings, B) strategies for coping with the effects of interview and interviewer characteristics on the interview’s reliability and validity, and C) areas of this still-growing topic that would benefit most from further research. By implementing the findings discussed in this review, employers and employees alike will be better equipped to make the best, most mutually beneficial use of the formal job interview

The implausibility of ‘usual care’ in an open system: sedation and weaning practices in Paediatric Intensive Care Units (PICUs) in the United Kingdom (UK)

Background: The power of the randomised controlled trial depends upon its capacity to operate in a closed system whereby the intervention is the only causal force acting upon the experimental group and absent in the control group, permitting a valid assessment of intervention efficacy. Conversely, clinical arenas are open systems where factors relating to context, resources, interpretation and actions of individuals will affect implementation and effectiveness of interventions. Consequently, the comparator (usual care) can be difficult to define and variable in multi-centre trials. Hence outcomes cannot be understood without considering usual care and factors that may affect implementation and impact on the intervention. Methods: Using a fieldwork approach, we describe PICU context, ‘usual’ practice in sedation and weaning from mechanical ventilation, and factors affecting implementation prior to designing a trial involving a sedation and ventilation weaning intervention. We collected data from 23 UK PICUs between June and November 2014 using observation, individual and multi-disciplinary group interviews with staff. Results: Pain and sedation practices were broadly similar in terms of drug usage and assessment tools. Sedation protocols linking assessment to appropriate titration of sedatives and sedation holds were rarely used (9 % and 4 % of PICUs respectively). Ventilator weaning was primarily a medical-led process with 39 % of PICUs engaging senior nurses in the process: weaning protocols were rarely used (9 % of PICUs). Weaning methods were variably based on clinician preference. No formal criteria or use of spontaneous breathing trials were used to test weaning readiness. Seventeen PICUs (74 %) had prior engagement in multi-centre trials, but limited research nurse availability. Barriers to previous trial implementation were intervention complexity, lack of belief in the evidence and inadequate training. Facilitating factors were senior staff buy-in and dedicated research nurse provision. Conclusions: We examined and identified contextual and organisational factors that may impact on the implementation of our intervention. We found usual practice relating to sedation, analgesia and ventilator weaning broadly similar, yet distinctively different from our proposed intervention, providing assurance in our ability to evaluate intervention effects. The data will enable us to develop an implementation plan; considering these factors we can more fully understand their impact on study outcomes

Implementation, impact and costs of policies for safe staffing in acute NHS trusts

The aim of this research has been to describe the implementation of safe staffing policies in NHS general acute Trusts in England looking at costs and consequences, and examining the factors that have influenced implementation. A mix of qualitative and quantitative methods were used (national survey, analysis of national data, four case studies, realist evaluation) to examine the impact of policies nationally, and explore commonality and variation in local responses to safe staffing policies. The report is based on independent research commissioned and funded by the NIHR Policy Research Programme (“Implementation, Impact and Costs of Policies for Safe Staffing in Acute NHS Trusts”, PR-ST-1115-10017). The views expressed are those of the authors and not necessarily those of the NIHR, the Department of Health and Social Care, ‘arm’s length bodies’ or other government departments

A pragmatic cluster randomised trial evaluating three implementation interventions

Background Implementation research is concerned with bridging the gap between evidence and practice through the study of methods to promote the uptake of research into routine practice. Good quality evidence has been summarised into guideline recommendations to show that peri-operative fasting times could be considerably shorter than patients currently experience. The objective of this trial was to evaluate the effectiveness of three strategies for the implementation of recommendations about peri-operative fasting. Methods A pragmatic cluster randomised trial underpinned by the PARIHS framework was conducted during 2006 to 2009 with a national sample of UK hospitals using time series with mixed methods process evaluation and cost analysis. Hospitals were randomised to one of three interventions: standard dissemination (SD) of a guideline package, SD plus a web-based resource championed by an opinion leader, and SD plus plan-do-study-act (PDSA). The primary outcome was duration of fluid fast prior to induction of anaesthesia. Secondary outcomes included duration of food fast, patients' experiences, and stakeholders' experiences of implementation, including influences. ANOVA was used to test differences over time and interventions. Results Nineteen acute NHS hospitals participated. Across timepoints, 3,505 duration of fasting observations were recorded. No significant effect of the interventions was observed for either fluid or food fasting times. The effect size was 0.33 for the web-based intervention compared to SD alone for the change in fluid fasting and was 0.12 for PDSA compared to SD alone. The process evaluation showed different types of impact, including changes to practices, policies, and attitudes. A rich picture of the implementation challenges emerged, including inter-professional tensions and a lack of clarity for decision-making authority and responsibility. Conclusions This was a large, complex study and one of the first national randomised controlled trials conducted within acute care in implementation research. The evidence base for fasting practice was accepted by those participating in this study and the messages from it simple; however, implementation and practical challenges influenced the interventions' impact. A set of conditions for implementation emerges from the findings of this study, which are presented as theoretically transferable propositions that have international relevance. Trial registration ISRCTN18046709 - Peri-operative Implementation Study Evaluation (POISE

Velocity profile of granular flows inside silos and hoppers

We measure the flow of granular materials inside a quasi-two dimensional silo as it drains and compare the data with some existing models. The particles inside the silo are imaged and tracked with unprecedented resolution in both space and time to obtain their velocity and diffusion properties. The data obtained by varying the orifice width and the hopper angle allows us to thoroughly test models of gravity driven flows inside these geometries. All of our measured velocity profiles are smooth and free of the shock-like discontinuities ("rupture zones") predicted by critical state soil mechanics. On the other hand, we find that the simple Kinematic Model accurately captures the mean velocity profile near the orifice, although it fails to describe the rapid transition to plug flow far away from the orifice. The measured diffusion length $b$, the only free parameter in the model, is not constant as usually assumed, but increases with both the height above the orifice and the angle of the hopper. We discuss improvements to the model to account for the differences. From our data, we also directly measure the diffusion of the particles and find it to be significantly less than predicted by the Void Model, which provides the classical microscopic derivation of the Kinematic Model in terms of diffusing voids in the packing. However, the experimental data is consistent with the recently proposed Spot Model, based on a simple mechanism for cooperative diffusion. Finally, we discuss the flow rate as a function of the orifice width and hopper angles. We find that the flow rate scales with the orifice size to the power of 1.5, consistent with dimensional analysis. Interestingly, the flow rate increases when the funnel angle is increased.Comment: 17 pages, 8 figure

Evaluating the successful implementation of evidence into practice using the PARiHS framework : theoretical and practical challenges

Background The PARiHS framework (Promoting Action on Research Implementation in Health Services) has proved to be a useful practical and conceptual heuristic for many researchers and practitioners in framing their research or knowledge translation endeavours. However, as a conceptual framework it still remains untested and therefore its contribution to the overall development and testing of theory in the field of implementation science is largely unquantified. Discussion This being the case, the paper provides an integrated summary of our conceptual and theoretical thinking so far and introduces a typology (derived from social policy analysis) used to distinguish between the terms conceptual framework, theory and model – important definitional and conceptual issues in trying to refine theoretical and methodological approaches to knowledge translation. Secondly, the paper describes the next phase of our work, in particular concentrating on the conceptual thinking and mapping that has led to the generation of the hypothesis that the PARiHS framework is best utilised as a two-stage process: as a preliminary (diagnostic and evaluative) measure of the elements and sub-elements of evidence (E) and context (C), and then using the aggregated data from these measures to determine the most appropriate facilitation method. The exact nature of the intervention is thus determined by the specific actors in the specific context at a specific time and place. In the process of refining this next phase of our work, we have had to consider the wider issues around the use of theories to inform and shape our research activity; the ongoing challenges of developing robust and sensitive measures; facilitation as an intervention for getting research into practice; and finally to note how the current debates around evidence into practice are adopting wider notions that fit innovations more generally. Summary The paper concludes by suggesting that the future direction of the work on the PARiHS framework is to develop a two-stage diagnostic and evaluative approach, where the intervention is shaped and moulded by the information gathered about the specific situation and from participating stakeholders. In order to expedite the generation of new evidence and testing of emerging theories, we suggest the formation of an international research implementation science collaborative that can systematically collect and analyse experiences of using and testing the PARiHS framework and similar conceptual and theoretical approaches. We also recommend further refinement of the definitions around conceptual framework, theory, and model, suggesting a wider discussion that embraces multiple epistemological and ontological perspectives