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

Deformation and Failure of Amorphous Solidlike Materials

Since the 1970's, theories of deformation and failure of amorphous, solidlike materials have started with models in which stress-driven, molecular rearrangements occur at localized flow defects via "shear transformations". This picture is the basis for the modern theory of "shear transformation zones" (STZ's), which is the focus of this review. We begin by describing the structure of the theory in general terms and by showing several applications, specifically: interpretation of stress-strain measurements for a bulk metallic glass, analysis of numerical simulations of shear banding, and the use of the STZ equations of motion in free-boundary calculations. In the second half of this article, we focus for simplicity on what we call an "athermal" model of amorphous plasticity, and use that model to illustrate how the STZ theory emerges within a systematic formulation of nonequilibrium thermodynamics.Comment: 28 pages, 4 figures, submitted to Annual Reviews of Condensed Matter Physic

Revised structure of haemoventosin

The structure of the lichen pigment haemoventosin has been revised to 3,4,6,9-tetrahydro-5,10-dihydroxy-7-methoxy-3S-methyl-1,6,9-trioxo-1H-naphtho-[2,3-c]pyran (3), mainly on the basis of long-range δC/δH correlations observed in 2D HMBC NMR experiments and long-range δH/δD isotope effects observed in partial deuteriation experiments with 10-O-acetylhaemoventosin; ortho- and para-quinonoid structures were distinguished by means of the transacetylation inferred in the sodium dithionite reduction of 10-O-acetylhaemoventosin

Stereospecific four-bond phosphorus-phosphorus spin couplings in phosphazenyl-phosphazenes

Four-bond phosphorus-phosphorus coupling constants have been measured from the 31P NMR spectra of phosphazenylcyclophosphazenes. Their magnitude appears to be related to the conformation adopted by the phosphazenyl-group relative to the phosphazene ring

Linking multiple biodiversity informatics platforms with Darwin Core Archives

This is an open access article distributed under the terms of the Creative Commons Attribution License (CC BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. The attached file is the published version of the article.NHM Repositor

Bioactive flavanones from Luma chequen

A bioassay-guided chemical study of a methanolic extract of fresh leaves of Luma chequen led to the isolation of lumaflavanones A (1), B (2) and C (3) whose structures are proposed on the basis of NMR spectroscopic data. The structure of lumaflavanone A was confirmed by X-ray analysis. Antifeedant (Spodoptera littoralis), brine shrimp (Artemia salina) and fungistatic (Botrytis cinerea) bioassays showed that while 3 was the most active in the first two assays the mixture of 1 and 2 was more effective as a fungistatic

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